				search

Advanced Preceptorship Registration Information

Registration Form

Required fields (*)

Advanced Preceptorship in Wound Healing

* Name (Last)

* Name (First)

Name (Middle)

* Company/Institution

* Degree

Other, Please list

* Mailing Address

* City

* State

(e.g. NJ)

Country

* Zip

* Daytime Phone

(e.g. 645-012-0000)

Fax

(e.g. 645-012-0000)

* E-Mail (for confirmation and communication purposes)

(e.g. barry@aol.com)

* Select Specialty

Other, Please List

Special Need

Check here if you require special services

Please describe your Special Need

* Please select the date you would like to attend *

1st Choice

2nd Choice

Please answer the following questions
(questions must be answered in order to process the application)

1) How many years have you been involved in treating patients with wounds?

2) How many surgical debridements/wound procedures do you perform each MONTH on average in the following settings:

A) Office:
B) Clinic or wound center:
C) Operating room:

3) What do you expect to learn from this course?

Payment

Registration Fee

$550

Your registration is not final until payment is complete. Please proceed to checkout. Please note we only accept MasterCard, Visa or Discover.

This fee includes academic presentations, course materials and meals and refreshments. Confirmation of registration will be sent upon receipt of the registration form and payment.

PLEASE NOTE: Registration is limited and will be handled on a first-come, first-served basis. Telephone registrations and/or cancellations are not accepted. Refund of registration fee, less a $50 administrative charge will be made if written notice of cancellation is received at two weeks prior to the meeting. No refunds can be made thereafter.

Accreditation and Credit Designation Statements
The College of Physicians and Surgeons of Columbia University is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The College of Physicians and Surgeons designates this educational activity for a maximum of 15 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The American College of Nurse Practitioners (ACNP) and The American Academy of Physician Assistants (AAPA) accept AMA/PRA category 1 credit from organizations accredited by the ACCME. The American Nurses Credentialing Center (ANCC) accepts AMA/PRA category 1 credit toward recertification requirements.

The New York College of Podiatric Medicine will provide DPM accreditation.