AO ASIF Interactive Spine Course
Registration Form

Please do not consider yourself registered for this course until written confirmation is received.

(Please type or print clearly)

Course Name:

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Name:

Degree(s):

Social Security Number (For documentation purposes only):

Guest's Name (if any):

Home Address (Street address only - No P.O. Box):

City:

State:

Zip:

Phone (office):

Phone (home):

Fax Number:

E-mail Address:

Hospital Affiliation:

City:

Have you ever attended an AO ASIF Course?: Yes No
If yes, when and where?:
Tuition Enclosed - U.S. currency only
Interactive Course*-$1025.00

*Interactive Course prerequisite: Attending surgeon. Practice should include 60 reconstructive spine surgeries annually.

Please mail this Registration Form and payment to:

AONA Continuing Medical Education
Re: Quebec Interactive Spine Course
1690 Russell Road
Paoli, PA 19301
Tel: (800) 769-1391/(610) 695-2459
Fax: (610)695-2420

Or submit online using a credit card.

Enclosed is my check for $ made payable to: AO ASIF Continuing Medical Education

Charge my credit card:

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Master CardVISAExp.Date: Card Number:
Signature (all credit card orders must be signed if mailing or faxing form):

PRE-COURSE QUESTIONNAIRE-MUST BE COMPLETED FOR REGISTRATION FORMS TO BE PROCESSED

2. Special Training: (check one) Neurosurgery Orthopaedic Other

3. As a participant in the Interactive Course, please check off what you expect to learn from the Course.

Latest advances and controversies in the treatment of complex spinal problems
AO principles and fixation techniques in spinal surgery for deformities, degenerative spine disease and inflammatory processes affecting the spine
Diagnostic problems and treatment methods for spinal conditions
Other

Please do not consider yourself registered for this course until written confirmation is received.

Please press this button
to submit your registration form:

Thank you.