Department of Anesthesia  Roy J. and Lucille A. Carver College of Medicine  University of Iowa Health Care  University of Iowa
  Regional Anesthesia Study Center of Iowa  The University of Iowa
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Registration Forms for Anesthesiologists

Register Online
Date of Workshop You Wish to Attend:*
Name:*
Profession:
Degree:
Address:*
City:*
State:*
ZIP:*
Country:*
Business Phone:*
Home Phone:
E-Mail Address:*
I work as: Private Anesthesiologist
Faculty in an academic department
PG1 PG2 PG3 PG4
Fellow CRNA SRNA
Medical Student
Other (please specify)

Institution:
Please estimate how many nerve blocks you perform per month: None Less than 10
Between 10 and 20 More than 50
What is your objective assessment of your own skill level in Regional Anesthesia? Novice Intermediate Advanced
I was referred to RASCI by:
I have special dietary preferences: Yes No

Please Specify:
Payment method: Cost:

$1,925 Two Day Regular Workshop

To pay by check, please send check to:
RASCI, Department of Anesthesia
ATTN: Lorri Barnes
University of Iowa
200 Hawkins Drive 6-JCP
Iowa City, IA 52242-1079

Please make checks payable to:
Department of Anesthesia, University of Iowa
* Indicates a required field.
Register Via Mail or FAX
Complete the PDF form below and mail or fax it to:
Regional Anesthesia Study Center of Iowa
University of Iowa Health Care
Dept. of Anesthesia
200 Hawkins Dr., 6 JCP
Iowa City, IA 52242-1079

Phone: 319-384-9273

FAX: 319-356-2940