Registration Forms for Anesthesiologists
Register Online
Date of Workshop You Wish to Attend:*
March 31-April 1, 2012
May 19-20, 2012 (pediatric)
October 6-7, 2012
December 1-2 2012
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
