Registration fee for Vanderbilt University School of Medicine/Corporate Health Services
"Medical Management of the Injured Worker XII" conference on March 8, 2013 is $200.00 for physicians (this includes CME fees) and $100.00 for all others.
This fee includes breakfast, lunch, breaks and conference materials.

PRE-REGISTRATION WILL END ON February 22, 2013.
Walk in registration will be available on the day of the conference for an additional $25.00.
NOTE:  Availability of conference materials and food cannot be guaranteed
for those who register on the day of the conference.

No registration fees will be refunded after March 1, 2013. Registration may be transferred to another person.

Discounts are available for multiple attendees from a single company.
Call Tammie Mathis at 615-936-2098 for more information on discounts.

NAME

COMPANY

STREET ADDRESS

CITY/STATE/ZIP CODE

PHONE/FAX NUMBER

E-MAIL ADDRESS

DESIGNATION:

Physician	Case Manager	Adjuster	Employer
Nurse	PT/OT	Attorney	Other

STAYING AT EMBASSY SUITES - COOL SPRINGS OR OTHER HOTEL?

YesNo

WHAT TYPE OF CEU'S DO YOU REQUEST?

CCMC (for case managers)

CME (for physicians)

CEU's (Kentucky Adjusters)

None

REGISTRATION FEES

$200 for MD's (this includes the cost of CME's)

$100 for Non-MD's

Other Amount

METHOD OF PAYMENT

PAY BY CHECK Make check payable to Vanderbilt Corporate Health Services

Mail Payment to:
Vanderbilt Corporate Health Services
Attention:Tammie Mathis
3319 West End Avenue, Suite 950
Nashville, Tn 37203

PAY BY CREDIT CARD

To insure your utmost security,
Tammie Mathis will contact you by phone to obtain your credit card specifics.
Be sure and provide the best phone number for this purpose!

REGISTRATION FOR 2013 CONFERENCE

DEMOGRAPHIC INFORMATION

FEES AND BILLING