Leading Edge Conference Registration Form

All fields are required.

Name:
Address:
City:
State:
Zip or Postal Code:
Country:
Telephone:
Fax:
E-mail:

Create A WebID

If you are a physician, please enter the last 4 digits of your Social Security Number. This will allow you to access your CME certificate via the Internet at the completion of the conference.

WebID:

All other registrants will receive SDMS Certificates via email at the completion of the conference. Please provide all applicable reference numbers from the list provided below.

SDMS#:
ARDMS#:
CARDUP#:
CCI#:
ARRT#:
Date of Birth:   (Format: MM/DD/YYYY)


What is your profession?

Physician: Specialty
Fellow
Resident
Sonographer
RT
RN
RVT
Other:

I want to subscribe to the JUREI Education Newsletter



How did you hear about JUREI?:

Colleague/Friend
Attended Previous Courses/Leading Edge
Mailing/Brochure
Referring Website      * web address (URL) of the referring website
Internet Search      * what search terms (keywords) did you use to find us?
Journal     

  * other journal's name



CONFERENCE:

Please indicate the date(s) you want to attend the Leading Edge in Diagnostic Ultrasound Conference. You must make a selection for each day. Select 'None' for days which you do not wish to attend.

Tuesday, May 21, 2013 (select only one)
Track:

Wednesday, May 22, 2013 (select only one)>
Track:

Thursday, May 23, 2013 (select only one)
Track:

 

Registration Fees

Physicians
  Before
4/19
After
4/19
On Site  
1 Day - T, W or Th $400 $450 $475
2 Days $725 $800 $850
Full Conference $925 $1,100 $1,200
Fellows/Residents/Allied Health Professionals
1 Day - T, W or Th $325 $375 $400
2 Days $525 $575 $600
Full Conference $750 $800 $850

Special Code:   optional

Payment Method:

Check

Credit card (AMEX, MC, or VISA)

Thank you for registering for the Leading Edge Conference.  Your registration will be complete once full payment is received.

Cancellation / Refund Policy:
Payment for registration must be made in U.S. funds. The registration fee, less an administrative charge of $100, is refundable if written notification of cancellation is received prior to April 19, 2013.  After that time refunds are not possible, but your payment less the administrative charge may be credited to a future course for use within one calendar year. Payment can be made by check, traveler's checks or credit card (American Express, MasterCard, or VISA). Foreign payments must be made by a draft on a United States bank.


Payment may be sent to the following address:
Radiology CME Program Manager, Ultrasound Institute
780 Main Building
Thomas Jefferson University Hospital
132 South 10th Street
Philadelphia, PA 19107-5244

Questions?

Contact us at (215) 955-8533 or Toll Free 1-888-390-5051 (USA only) or Fax (215) 923-9452 or e-mail (jurei@jeffersonhospital.org)