Attendee Name. ASDS Member ID#. Address NOTE: Exhibitors will receive registrant mailing addresses â you may wish to u
2017 ASDS Annual Meeting Registration Form Register online at asds.net/AnnualMeeting
Complete a separate form for every registrant – Print clearly.
Attendee Name
ASDS Member ID#
Address NOTE: Exhibitors will receive registrant mailing addresses – you may wish to use your preferred business address rather than your home address. City
State / Region
Postal Code
Phone (include country code outside U.S.) Email (for ASDS communication only)
Country
Mobile (include country code outside U.S.) Fax (include country code outside U.S.)
Name on Badge ____________________________________________
□ ADA / SPECIAL ASSISTANCE For accessibility requirements,
food allergies, or strict dietary restrictions please email
[email protected]
Payment Information (U.S. dollars only) Full payment in U.S. dollars is due upon application submission. Refunds, less a $100 administrative fee, are allowed for cancellations received at ASDS in writing by Sept. 8. After that date, no refunds are permitted.
$_________________ Subtotal Page 1: Subtotal Page 2: $_________________ TOTAL MEETING FEE: $_________________ CREDIT CARDS: Fax completed forms to 847-956-0999
□ Visa
□ MasterCard
□ American Express □ Discover
Credit Card #_________________________________________________ Expiration Date ________________ Billing Address ZIP _______________ Authorized Signature___________________________________________
Meeting Registration Categories and Fees *Select Best Value Package and save $80 over purchasing Recording Package separately. All Best Value purchasers will be entered into a drawing for a complimentary 2018 ASDS Annual Meeting registration. See Special Offerings to purchase after Sept. 8.
1) ASDS Members (Including Adjunct) 2) Residents / Post-residency Trainees Graduating resident class of 2017 or after;; currently in a clinical or academic fellowship from July 2017 to June 2018 (U.S. & Canada only)
3) ASDS Life Members 4) Non-member Dermatologists Refer to Non-member Eligibility Requirements.
Proof of board certification in dermatology must accompany your registration application.
5) Surgical Assistants / Office Staff / ADAM Members
Includes admission to exhibit hall, receptions and all non-cosmetic sessions (marked ✦)
Employing Dermatologist’s Name _____________________________________________
6) Guests (Spouse/Companion) Must be a guest of a registrant in category 1, 2 or 3 above. Includes admission to exhibit hall and receptions;; no scientific sessions.
Name ____________________________________________________________________
7) Medical Students Letter from your Medical School Dean must accompany your registration.
By virtue of registration, ASDS Annual Meeting attendees agree to abide by the Meeting Policies and Code of Conduct, and that photos taken by ASDS will be utilized in future meeting promotions.
CHECKS (Allow 7 additional business days for processing.) Send checks payable in U.S. dollars to: American Society for Dermatologic Surgery 5550 Meadowbrook Drive, Suite 120 Rolling Meadows, IL 60008-3805
*Best Value Advance Reg and AM Recordings
On or Before 9/8/17
17AMBVM
17AMM
17AMML
17AMBVR
17AMR
17AMRL
$878
After 9/8/17 or On-site
$779
$368
$979
$269
$278
$469
$179
$379
17AMBVLF
17AMLF
17AMLFL
$1,709
$1,559
$1,759
17AMBVN
$229
Not Available
Not Available
17AMNL
17AMN
$429
17AMSA
$200
17AMGST
17AMSAL
$399
17AMGSTL
$179
Not Available
$249
17AMMS
17AMMSL
Special Offerings Saturday, 7 – 11 p.m.
Twelfth Annual Gala Reception and Dinner Note: if registering online, Current Lifetime,
Sustaining and Stegman Circle member donors receive two complimentary Gala tickets by calling ASDS at (847) 956-0900. Member / Guest name provided will be assigned the complimentary tickets unless otherwise specified.
Name(s) of person(s) attending: ___________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
ASDS Annual Meeting Recordings (ordered after Sept. 8 or on-site) Registering before Sept. 8? Recordings are included in Best Value Package
No. of Tickets _____@ $145 17GALA
$
Office Use Only:
No. Tickets _________comp
17COMPGALA
ASDS Member $129 Non-Member $179
$
Subtotal Page 1 $ For questions, please call 847-956-0900 (8:30 a.m. – 5 p.m. CT)
2017 ASDS Annual Meeting Registration Form Page 2 - Complete a separate form for every registrant – Print clearly. Name___________________________________________________ ID#_____________ Afternoon Targeted Talks are complimentary and available on a first-come basis at the door. Sessions marked with ✦ are open to Office Staff, Surgical Assistants and ADAM members.
Wednesday, Oct. 4
Pre-conferences and Hands-on Workshops
9:30 a.m. – Noon
Primer on Anatomy for Injectables, Tumor Excision / Wound Repair and Veins
$75 17PCANA
$
2 – 5 p.m.
Hands- on Workshop: Advanced Sclerotherapy and Vein Techniques
$
Hands- on Workshop: Tumor Excision / Wound Repair
$195 17PCWSV
2 – 5 p.m.
$195 17PCWST
$
1:30 – 4:30 p.m. Hands-on Workshop: Injectable Techniques
CLOSED - Check onsite for availability
$195 17PCWSF
$ CLOSED Yes No
3 – 4:30 p.m.
Journal Article Reviewers’ Workshop
N/C 17JARS
6 – 9 p.m.
ASDS Unplugged – Straight Talk About Devices and More
$79 17PC $ $59 Guest 17PCG
(Dinner included;; advance registration required)
Thursday, Oct. 5 8 – 9:15 a.m.
Special Session: Leading-edge Lasers and Energy-based Technologies
8 – 9:15 a.m.
Morning Masters AB101 • Hard as Nails: Advanced Nail Surgery Videos ✦ AB102 • Feeling Unflappable: Techniques for Flap Success ✦ AB104 • Da Vinci Code: Deciphering Dermatopathology Reports ✦ AB105 • David and Goliath: Practice Size and Sophistication ✦ AB106 • From Bruises to Blindness: Minimizing/Avoiding Cosmetic Complications: Injectables
12:15. – 1:30 p.m.
Resident Luncheon
(Residents / Post-residency Trainees only) Advance registration required.
$50 17EBS
$
$60 Choice 1______
$
Choice 2______
N/C 17RL
Yes No
N/C 17BC
Yes No
Friday, Oct. 6 8 – 9:15 a.m.
The Leading-edge in Cosmetic Dermatology Fundamentals
8 – 9:15 a.m.
Morning Masters AB201 • Making Surgical Complications Less Complicated AB202 • Scholarly Skin Pursuits: Literature Review of Skin Cancer and Reconstruction✦ $60 AB203 • Refinements in Nasal Reconstruction ✦ Choice 1______ AB204 • Eye Candy: How to Create Videos that Resonate ✦ Choice 2______ AB205 • Human Resource Management in a Successful Dermatology Practice ✦ AB206 • The Art of the Cosmetic Consult in Every Type of Practice ✦ AB207 • Better Slides: Improving your Mohs Histology ✦
10:45 a.m. – 12:15 p.m.
Patient Demo and Hands-on Mini-workshop: Sclerotherapy and Vein Techniques
$95 17PD215
$ CLOSED
Noon – 1:45 p.m.
Research Luncheon Session and Cutting Edge Research Abstracts: Who are the Experts? A Critical Analysis of the Scientific Literature
$35 17RSCHL
$
CLOSED - Check onsite
$95 17WS225
(Lunch included;; advance registration required)
1:45 – 3:30 p.m. Hands-on Mini-Workshop: Advanced Suturing Techniques 7 – 8 p.m.
Resident Networking Reception (Residents and Resident Guest only) Advance registration required.
$
CLOSED
N/C Resident 17RD Yes No $25 Guest 17RDG $
Saturday, Oct. 7
8 – 9:15 a.m.
Morning Masters AB301 • Refinements in Perioral Reconstruction✦ AB302 • Relax with Paralax: Core Curriculum in Neuromodulators AB303 • Skipping Along the Tension Lines: Transposition Flaps ✦ AB304 • Comprehensive Management of Ethnic Skin ✦ AB305 • Menaissance: Unique Aspects of Treatment of the Male AB307 • Women’s Health
$60 Choice 1______ Choice 2______
$
3:30 – 5 p.m.
Hands-on Mini-workshop: Soft-tissue Filler and Neuromodulator Techniques
$145 17WS350
$ CLOSED
$90 17WS410
$ CLOSED
Sunday, Oct. 8 8:30 – 11:30 a.m.
Hands-on Workshop: Tumor Excision / Wound Repair and Injectable Techniques Residents/Post-residency Trainees only CLOSED - Check onsite
For questions, please call 847-956-0900 (8:30 a.m. – 5 p.m. CT)
Subtotal Page 2 $
