Registration - Racz Lab

Select Racz Workshop Location*

First Name*

Last Name*

Titles*

Practice Name*

Email*

Phone*

Medical School*

Residency*

Fellowship*

Glove Size*

How did you hear about Racz Lab?*

Please specifiy how you heard about Racz Lab:*

What are you interested in learning at the workshop?*

What do you hope to accomplish or gain while at the workshop?*

Medical Degree*

MD
DO
PHD
Other Medical Degree

Other Medical Degree*

Current Board Certifications*

American Board of Anesthesiology
American Board of Pain Medicine
American Board of Psychiatry and Neurology
American Board of Physical Medicine & Rehabilitation
ABA Subspecialty in Pain Medicine
Fellow of Interventional Pain Practice (FIPP)
American Board of Interventional Pain Physicians (ABIPP)
Other Board Certifications

Other Current Board Certifications*

Specialty Designation*

Radiology
Physical Medicine & Rehab
Anesthesiology
Neurosurgery
Neurology
Other Specialty

Other Specialties*

Primary professional practice setting(s)*

Ambulatory Surgery
Hospital
Office Practice
Academic
Administrative
Military / VA
Other Practice Setting(s)

Other Practice Setting*

Which interventional techniques do you perform at your practice?*

Other Techniques*

What percentage of your clinical practice is in the field of Interventional Pain Management?*

0%
1-49%
50-100%

Years in Interventional Pain Management*

0
1-5
6-10
10+

Meal Preference*

Vegetarian
Vegan
None

Allergies*

Milk
Soy
Nuts
Gluten
None
Other Allergies

Other Allergies*

Credit Card Billing Address*

Credit Card Billing Address 2

City*

State Province*

Postal Code*

Country*

Credit Card*

American Express

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Purchase Terms and Conditions*

I have read and agree to the site's Cancellation, Terms of Use, and Privacy Policies.

*Space is limited. Please register ASAP.
*Registrants are screened and pre-qualified.
*Only physicians may attend a workshop.
*The fee is non-refundable.
*In most cases, attendance must be confirmed 30 days prior to the workshop date.
*Attendee is responsible for their own air travel, hotel, and transportation.

PLEASE NOTE: Attendees who fall ill before or during the event, will be asked to leave for the safety and well-being of others in attendance.

Cancellations:
In most cases, attendance will be verified at least 30 days prior to the workshop date. The workshop fee is non-refundable for approved applicants, regardless of attendance. In rare cases in which an applicant does not qualify to attend a workshop, a 100% refund will be issued. Refunds can take up to 30 days to process.

Terms of Use:
Read Terms of Use

Privacy Policy:
Read Privacy Policy

Coupon

Total

$0.00

Email

This field is for validation purposes and should be left unchanged.

RACZ WORKSHOP REGISTRATION

Need CME Accreditation?

Travel Visa Information

About

Legal

At a Glance