ISSUES IN WOMEN S HEALTH

Transcription

1 Exciting News our hotel room rates include daily buffet breakfast! Please look inside this brochure for more details. 26 th Annual Fall Conference on ISSUES IN WOMEN S HEALTH Including topics on: Sexual Health, Dermatology, Diabetes, Breast Cancer, Urinary Incontinence, and much more Hyatt Regency Maui Resort & Spa MAUI, HAWAII OCTOBER 31 - NOVEMBER 3, 2018 SPONSORED BY Symposia Medicus has the execution of conferences down to a science. The choice of speakers has constantly been excellent, so the depth of knowledge gained is very valuable and useful in medical practice. D. Hotmer, MD Once again, Symposia Medicus knocked it out of the ballpark! Interactive, informative, and important to our practice! V. Thomas, BSN This is an excellent conference! I learned so much and the presenters were fun and interesting. I always look forward to the next day! K. Asher-Galloway, CNM Register On-Line... for this conference or view other educational conferences at Page 13 Conference Brochure #1471, 26 th Annual Fall Conference on Issues in Women s Health Symposia Medicus

2 CONFERENCE DESCRIPTION Our 26 th Annual Fall Conference on Issues in Women s Health is designed to provide the most current clinical information about the care of the female patient to OB/GYNs, family physicians, nurse midwives, nurse practitioners, PAs, nurses and all other healthcare professionals involved with the care of women. The goal of this conference is to increase knowledge and enhance the competence of attendees. Emphasis will be placed on practical application of the evidence-based topics presented. Topics for this year s conference have been selected based on the educational needs determined from the identified professional practice gaps. The gaps were derived from a variety of sources including evaluations and outcomes data from past participants; clinical expert input; Symposia Medicus online survey; and other medical and nursing data. Conference format will include didactic lectures, smaller group breakout and interactive sessions, case studies, and question and answer sessions. An outstanding faculty has been assembled for this conference. Each member was selected based on their individual area of expertise and ability to communicate current, evidence-based, and practical information to participants. You are sure to enjoy our 26 th Annual Fall Conference on Issues in Women s Health while sharing ideas and experiences with colleagues from across the country in the beautiful setting of Maui. CONFERENCE OBJECTIVES As a result of participating in this conference, you should have increased knowledge and enhanced competence to Appropriately prescribe newer medications for type 2 diabetes Construct a treatment plan for women with stress or urge incontinence Review triage recommendations for abnormal cervical screening Name the five essential components of a comprehensive sexual history Diagnose and manage women with chronic vulvar pain ATTENDEE REQUIREMENTS At the conclusion of attending this conference, participants are entitled to a certificate of credit which will be available online. Successful completion of this activity is determined by attending the live activity, review of the educational session materials, and submission of the case study test, evaluations, and attendance verification form. Each participant should only claim credit commensurate with the extent of their participation in the activity. ACCREDITATION This educational activity was planned and produced in accordance with the ACCME and ANCC Essentials and Standards relating to continuing medical and nursing education. Symposia Medicus is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. Symposia Medicus is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. CONTINUING EDUCATION CREDIT Physicians Symposia Medicus designates this live activity for a maximum of 18 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ACOG The American College of Obstetricians and Gynecologists has assigned up to 18 cognate credits to this program. AAFP This Live activity, 26 th Annual Fall Conference on Issues in Women s Health, with a beginning date of 10/31/2018, has been reviewed and is acceptable for up to Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Certified Nurse Midwives The American Midwifery Certification Board (AMCB) accepts Category 1 CME approval from organizations accredited by the ACCME. PAs NCCPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit from organizations accredited by ACCME or a recognized state medical society. PAs may receive a maximum of 18 hours of Category 1 credit for completing this program. Nurse Practitioners/Nurses The ANCC contact hours awarded for completion of this conference are 18. Provider is also approved by the California Board of Registered Nursing, Provider #CEP2335, for 21.6 contact hours. Pharmacology Credit for Prescriptive Authority A maximum of 3.75 hours in pharmacology credit for prescriptive authority may be earned by attending this educational conference. Sessions awarding pharmacology credit for prescriptive authority are denoted with an Rx in the schedule. SMALLER GROUP BREAKOUT SESSIONS Smaller group sessions will be held Friday afternoon. These breakout sessions are organized to provide greater participant/faculty interaction, and will give you an opportunity to participate in discussions on subjects relating to your particular area of interest. Please indicate your breakout session topic choices on the conference registration form in this brochure. Space is limited so please reserve early. EDUCATIONAL RESOURCES Each registrant will have online access to session materials. The session materials will be available for download approximately two weeks prior to the conference (you ll receive an with instructions). If you wish to receive a hard copy of the session materials, please check the box on the registration form in this brochure. If you are unable to attend this conference, extra copies of the session materials (either paper or digital copy) will be available one week after the conference. The cost is $60 for a hard copy and $25 for the digital copy. To place your order, please publications@symposiamedicus.org. GROUP TOURS / GROUND TRANSPORTATION To receive additional information about the conference hotel, location, tours and/or nearby attractions, and ground transportation, please visit our website at Page 23 Conference Brochure #1471, 26 th Annual Fall Conference on Issues in Women s Health Symposia Medicus

3 CONFERENCE FACULTY Medical Director International Diabetes Center Endocrinologist & Medical Director of the Diabetes Program, HealthPartners Assistant Professor University of Minnesota Medical School Minneapolis, Minnesota Conference Co-Chair Adjunct Associate Clinical Professor University of North Carolina Chapel Hill, North Carolina Chief of Dermatology Carolinas Medical Center Charlotte, North Carolina Conference Co-Chair Professor Vice Chairman Director of Philadelphia Fibroid Center Department of OB/GYN Einstein Medical Center Philadelphia Philadelphia, Pennsylvania Professor & Division Director of Urogynecology Department of Obstetrics & Gynecology Adjunct Professor of Urology University of Washington Medical Center Associate Editor, ACOG Clinical Updates in Women s Health Care Seattle, Washington Evelyn Resh CNM, MPH, CSC, MSN AASECT Certified Sexuality Counselor Chair, AASECT Credentialing Committee for Sexuality Counselors Clinical Nurse-Midwife Planned Parenthood League of Massachusetts Thrive Integrative Psychiatry & Sexuality Counseling Northampton, Massachusetts DISCLOSURE STATEMENT Consistent with ACCME and ANCC guidelines, it is the policy of Symposia Medicus to ensure balance, independence, objectivity, and scientific rigor in all educational activities. Prior to the planning of this educational activity, all individuals in a position to influence and/or control the content of continuing education activities have been asked to disclose all relevant financial relationships within the past 12 months. Beyond disclosure of relevant financial relationships, faculty are required to disclose when they plan to discuss pharmaceuticals and/or medical devices that are not approved by the FDA and/or medical or surgical procedures that involve an unapproved or off-label use of an approved device or pharmaceutical. Symposia Medicus is committed to providing learners with commercially unbiased continuing education activities. This information is intended to assist learners in forming their own judgments about the content presented. Disclosure information will be included in the session materials for this activity, and speakers will provide a slide disclosure for each presentation, and will also verbally disclose on-site. CONFERENCE SCHEDULE Wednesday, October 31 7:00am Registration & Check-in 8:00 Welcome & Introduction 8:15 Female Urinary Incontinence: Diagnosis & Treatment (Rx = 20 minutes) 9:00 Update & Treatment Options for Uterine Fibroids (Rx = 15 minutes) 9:45 Questions & Answers 10:15 Break 10:30 Management of Chronic Vulvar Symptoms (Rx = 15 minutes) 11:15 Taking a Sexual Health History: Easier Said Than Done & Why It s Critically Important Evelyn Resh, CNM, MPH, MSN Noon Pitfalls & Pearls of Thyroid Disease Management (Rx = 15 minutes) 12:45pm Questions & Answers 1:30 Adjourn for the Day 5:30- Group Reception 7:00 (Faculty, Participants, and Guests) Thursday, November 1 8:00am Diabetes: Challenging Cases (Rx = 30 minutes) 8:45 Cervical Screening & Treatment Update (Rx = 15 minutes) 9:30 Questions & Answers 10:00 Break 10:15 Difficult Treatment Decisions in Osteoporosis (Rx = 30 minutes) 11:00 Update on Breast Cancer Screening & Mammographic Breast Density (Rx = 15 minutes) 11:45 Sex Counseling & GYN Care: Skills for Practitioners in Women s Health Evelyn Resh, CNM, MPH, MSN 12:30pm Questions & Answers 1:15 Adjourn for the Day Friday, November 2 3:00pm Smaller Group Breakouts Session One 4:30 Break A. Diabetes Technology in 2018: Devices, Apps, and Beyond B. Puzzling Dermatologic Vulvovaginal Cases C. Women s Health Care Risk Management: Case Studies D. Keys to Managing Abnormal Uterine Bleeding 4:45 Smaller Group Breakouts Session Two (Session One Topics Repeated) 6:15 Adjourn for the Day Saturday, November 3 8:00am Bladder Problems That Aren t Incontinence (Rx = 20 minutes) 8:45 Skin Cancers & Sun Damage (Rx = 15 minutes) 9:30 Questions & Answers 10:00 Break (hotel check-out, if applicable) 10:15 Conservative & Surgical Options for Pelvic Organ Prolapse (Rx = 20 minutes) 11:00 Assessing & Managing Hypoactive Sexual Desire Disorder for GYN Providers (Rx = 15 minutes) Evelyn Resh, CNM, MPH, MSN 11:45 How to Diagnose Skin Disease Using Diagnostic Algorithms 12:30pm Questions & Answers 1:15 Conference Adjourns Rx = Pharmacology Credit for Prescriptive Authority will be granted for these sessions Page 3 Conference Brochure #1471, 26 th Annual Fall Conference on Issues in Women s Health Symposia Medicus

4 CONFERENCE REGISTRATION, LODGING, & TRAVEL INFORMATION Enrollment for this conference is limited in order to provide the best possible learning environment. Early registration is advised. You can register and receive conference lodging group rates by reserving the following ways: On-line at our website, OR Call Monday-Friday, 8:30am-5:00pm (Pacific Time), (925) with Visa, MasterCard, American Express, or Discover; OR By mail, make check payable to Symposia Medicus and send with registration form to 399 Taylor Blvd., Suite 201, Pleasant Hill, CA Visit or call (925) for additional questions or information. CONFERENCE REGISTRATION INFORMATION TUITION: EARLY REGULAR If postmarked by If postmarked after August 22, 2018 August 22, 2018 Physicians $675 $775 Residents, Nurses, PAs & All Others $575 $675 Discounts are available for retired healthcare providers, active U.S. military, and groups of three or more. For more information, please contact Symposia Medicus prior to registering. Tuition includes continuing education, online access to session materials, and break refreshments for conference registrants. Tuition also includes group reception for faculty, registrants, and their guests. Conference registration will be confirmed via AIR TRAVEL INFORMATION You will be flying into Kahului Airport (OGG), which is approximately 28 miles from the Hyatt Regency Maui Resort & Spa. To find information on ground transportation, please visit our website. Symposia Medicus has arranged for discount fares with Alaska, Delta, Hawaiian, and United airlines for this conference. Reservations can be made either through your travel agency or through the airlines at the website or Convention Desk numbers listed below. In order to receive the discounted rate, you or your travel agent must refer to the Symposia Medicus Group ID number listed here. Alaska Delta Hawaiian United CAR RENTAL DISCOUNT For discounts on Alaska flights, please book online at and click on the link Use Discount Code, located at the bottom of the Book Flights box. Once you click on this link, another page will appear. On this page, you will need to insert ECMZ304 in the Discount Code box, located at the right-hand side of the page. For discounts on Delta, please visit and click on the link Advanced Search, located at the bottom of the Book a Trip box. Once you click on this link, another page will appear. On this page, you will need to insert NMQC4 in the Meeting Event Code box, located at the right-hand side of the page. For questions, please call the Delta Convention Desk at (800) For discounts on Hawaiian flights, please book online at and insert SYMPOSIA MED into the Preferred Affiliate Program Code box, located at the right-hand side of page. For discounts on United, please visit and click on All Search Options, located on the bottom left corner of the Book Travel box. Once you click on this link, another page will appear. At the bottom of this page, you will insert ZE2C in the Promotions and Certificates box. For questions, please call the United Convention Desk at (800) For conference discounts, Symposia Medicus has made arrangements with AVIS and Budget Car Rentals. Reservations can be made by phone; please refer to the conference code and the conference/airport location when making your reservations. Please see below: AVIS AWD #B Budget BCD #U CONFERENCE LODGING INFORMATION Conference group rates have been arranged at the Hyatt Regency Maui Resort & Spa. Rooms at our group rates are limited and on a first come, first served basis. PLEASE RESERVE EARLY as rooms may sell out and/or room rates may increase. If you wish to extend your stay, group rates may be available three days before and three days after the conference. Two nights deposit (room rate only) must accompany your reservation. The balance of your lodging, hotel fees as stated below, and all incidental charges are due to the hotel. The hotel accepts most major credit cards. GROUP RATES STATED BELOW INCLUDE DAILY BUFFET BREAKFAST FOR TWO PEOPLE Room Type View Group Rates Description (Single/Double) Golf Mountain View of the West Maui Mountains $270/night View and Ka anapali golf courses Partial Ocean Partial view of the Pacific Ocean $320/night View from the lanai Deluxe Ocean Full view of the Pacific Ocean, $360/night View overlooking the hotel grounds, pool, and ponds Deluxe Ocean Unobstructed view of the $400/night Front Pacific Ocean and the islands of Lana i and Moloka i By booking your lodging with Symposia Medicus, the Resort Fee charge of $32.00 plus 4.166% tax, per room, per night is discounted to $15.00 plus tax. The Resort Fee includes (subject to change): in-room & throughout resort standard Wi-Fi, two reusable keepsake water bottles (per room, per stay, upon arrival) with access to refillable water stations throughout the resort, 24-hour access to the oceanfront Stay Fit gym, daily yoga/ fitness classes, local, 1-800/1-888 phone calls, in-room safe, in-room coffee/tea, resort shuttle service to/from Ka anapali, one hour daily tennis or basketball court time, lei greeting upon arrival, 10% off at Macy s (located in the hotel), resort shuttle service in Ka`anapali (trolley), cultural programs including lei making & hula lessons, wildlife tours, penguin and koi feedings, PressReader (digital newsstand), concierge services through Expedia Local Expert, personalized guest request texting service (see front desk for more details), discounted pricing for in-house guests at Drums of the Pacific Luau, 25% discount on greens fees at Ka anapali golf courses (Royal & Kai Courses), 10% discount on all non-sale apparel items at the Ka anapali Golf Course Pro Shop, complimentary beach portrait session, and 5x7 print from Grins2Go at Hyatt Regency Maui. TERMS & CONDITIONS Hotel Policies Symposia Medicus guests will also receive a 25% discount on hotel s two person cabanas (advance reservations are required and are based on availability). Above conference group rates are per room, per night and do not include the following (subject to change): % state & local taxes - $15.00 (plus 4.166% tax) resort fee (discounted from $32.00) - $12.00 (plus 4.166% tax) per person (regardless of age), round-trip porterage (bellman) fee Suggested (non-mandatory) housekeeping gratuity of $4.50 per room, per day Maximum guestroom occupancy is four, regardless of age (5th guest allowed if it is an infant under 12 months old, subject to crib rental fee, if needed) Mandatory additional person charges (below) include daily buffet breakfast, taxes, and gratuities: - Children 4 years and under are FREE - Children 5 to 12 years old are $16/person, per night - Children 13 to 18 years old are $36/person, per night - Adults 19 years and older are $86/person, per night Bed Type Requests: You can select one or two beds; however, requests cannot be guaranteed until check-in Rollaways & Cribs: Rollaway beds and cribs are $25 each, per night (based on availability and subject to change). Only one crib or one rollaway is allowed in each room. Check-in time is 4:00pm and check-out time is 11:00am. A late check-out can only be confirmed on the date of departure by the front desk. Additional charges may apply for late check-outs and are based upon availability. Early Departure Fee: Please confirm your scheduled departure date with the hotel prior to check-in. An early departure fee equal to one night s room and tax will be charged to any guest who checks-out of the hotel before their confirmed departure date. Credit/Debit Card Policy: Upon check-in, the hotel requires a credit card or debit card to ensure that funds are available. Holds are placed on your account for your entire stay; however, the amount may be immediately deducted from your account. The length of time for which these holds remain on your credit or debit account varies from bank to bank. Parking: Self-parking is discounted to $15 per day, for conference guests. Valet parking is available at $28 per day (subject to change). Cancellation Policies All rooms are approximately 450 sq. ft., include a lanai or balcony, and feature an iron/ironing board, robes, hair dryer, 37 inch LG LCD flat screen TV, and an ihome alarm clock radio. Rooms have either a king bed with a full size sofa pull-out or one queen bed with one double bed. Conference cancellations must be made in writing (via or mail) to Symposia Medicus and a refund, less a 10% processing fee, will be given. No refunds will be made if cancellation is received after September 26, 2018; however, tuition, less 10% processing fee, may be applied to a future Symposia Medicus conference. Per our hotel contract, hotel reservation cancellations must be made in writing to Symposia Medicus and you will receive a full refund if ed/postmarked by August 29, Between August 30, 2018 and September 26, 2018, one night s deposit is forfeited. After September 26, 2018, no hotel refunds can be made. All cancellations must be ed to registrar@symposiamedicus.org OR mailed to Symposia Medicus. If mailed, it must be postmarked by the dates stated above. In the unlikely event of conference cancellation by Symposia Medicus, full tuition and, if reservation was made with Symposia Medicus, hotel deposit refunds will be made. Symposia Medicus will not be responsible for refunding travel or any other expenses. In the unlikely event of conference cancellation by Symposia Medicus, full tuition and, if reservation was made with Symposia Medicus, hotel deposit refunds will be made. Symposia Medicus will not be responsible for refunding travel or any other expenses. Page 43 Conference Brochure #1471, 26 th Annual Fall Conference on Issues in Women s Health Symposia Medicus

5 CONFERENCE LOCATION Aloha! The magical island of Maui, land of legend and incredible beauty, is the setting for our 26 th Annual Fall Conference on Issues in Women s Health. Famous for its breathtaking beauty and spectacular white sand beaches, Maui is also dramatically covered with mountain slopes and lush valleys. Situated on 40 spectacular oceanfront acres along the famed Ka anapali Beach, the Hyatt Regency Maui Resort & Spa offers unlimited activities and amenities in a setting of tropical luxury. The resort is just four miles north of historic Lahaina town and a short walk from Whaler s Village for shopping, dining, art, boating excursions and night life. With unparalleled panoramic views of the magnificent Pacific Ocean, the resort puts you close enough to hear the waves from your guestroom while enjoying the gentle breezes of paradise. Enjoy additional amenities at the new Hyatt Residence Club, located in the north end of the resort. Swim and relax in four new pool areas, including a zero-entry lagoon and an infinity relaxation pool with ocean views. Cool off with a refreshing drink at Pau Huaka i, a beachfront Tiki Bar, and pick up items to go, including delicious gourmet foods and wine at the Lahaina Provision Company market and deli. For shopping at the hotel, Macy s Hyatt Regency offers a first class selection of top fashion brands including Ralph Lauren, Calvin Klein, Clinique, Estee Lauder & Levis. Spend the day pampering yourself at the Marilyn Monroe Spa, play a round of championship golf at the Royal Ka anapali Course and Ka anapali Kai Course, or hit the court for a tennis match. For authentic Island adventure, go snorkeling at Black Rock, enjoy an authentic Polynesian Lu au, or ride the Pacific waves at the white sand beach. Whatever your pleasure, you ll be sure to find it on Maui, at our 26 th Annual Fall Conference on Issues in Women s Health. For our complete calendar of conferences, please visit Brochures are available 6-8 months prior to the conference CALENDAR OF FUTURE CONFERENCES th Annual Spring Conference on High Risk Obstetrics Los Cabos, Mexico Mar th Annual Spring Conference on Women s Health St. Kitts, Caribbean Mar th Annual National Conference on Fetal Monitoring Las Vegas, Nevada Apr th Annual Spring Conference on Integrative Medicine in Women s Health Ojai, California Apr rd Annual Conference on High Risk & Critical Care Obstetrics New Orleans, Louisiana May rd Annual Conference on Challenges in Sexual Healthcare Napa, California May Challenges in Mental Healthcare for the Primary Care Provider Napa, California Jul th Annual Summer Conference on Women s Health Big Island, Hawaii Jul Hot Topics in Pediatric Emergencies Alaska Cruise (Celebrity Cruises Solstice) Jul 27-Aug th Annual Summer Conference on Obstetrics & Gynecology Naples, Florida Aug th Annual Fall Conference on Integrative Medicine in Women s Health Sedona, Arizona Sep th Annual National Conference on Women s Health Care Las Vegas, Nevada Sep Challenges in Obstetrics & Gynecology Mediterranean/Adriatic Cruise (Celebrity Cruises Constellation) Sep nd Annual Fall Conference on High Risk Obstetrics San Francisco, California Sep th Annual Fall Conference on Obstetrics Guanacaste, Costa Rica Oct Current Issues in Women s Health Rhine River Cruise (AMA Waterways AmaStella) Oct 29-Nov Hot Topics in Pediatric Emergencies Rhine River Cruise (AMA Waterways AmaStella) Oct 29-Nov th Annual Fall Conference on Hot Topics in Primary Care Grand Cayman, Cayman Islands Oct 31-Nov th Annual Fall Conference on Challenges in Taking Care of the High Risk Pregnancy Naples, Florida Nov th Annual Conference on Women s Health: Care of Women Over 50 Grand Cayman, Cayman Islands Nov th Annual Conference on Challenges in Gynecology New York City, New York Dec nd Annual Conference on Emergencies & Challenges in Primary Care New York City, New York Dec Page 53 Conference Brochure #1471, 26 th Annual Fall Conference on Issues in Women s Health Symposia Medicus

6 CONFERENCE & LODGING REGISTRATION FORM Register on-line at OR COMPLETE THIS FORM AND MAIL WITH APPROPRIATE PAYMENT TO: Symposia Medicus 399 Taylor Blvd., Suite 201 Pleasant Hill, CA Phone: (925) PLEASE PRINT LEGIBLY: (Show name and one degree as you would like it printed on your conference materials) SYMPOSIA MEDICUS 26 th Annual Fall Conference on ISSUES IN WOMEN S HEALTH Hyatt Regency Maui Resort & Spa MAUI, HAWAII OCTOBER 31-NOVEMBER 3, 2018 Registrant s Name: Degree: First Last Registrant Address (required): All registrants must provide their individual address in order to register for this conference. Confirmation/receipt will be ed to this address. an additional copy of my confirmation/receipt to: (Provide additional address) Mailing Address: Street City State Zip Check if above address is: Work Home Provide office/workplace name here: Primary Work: ( ) Home: ( ) Cell: ( ) Fax: ( ) Professional Specialty: The session materials will be available (for all participants) to download from our website approximately two weeks before the conference. If you prefer to also receive a hard copy of the session materials, please check here FRIDAY BREAKOUT PREFERENCE (Please refer to schedule and select one breakout for each session): Session One: A B C D Session Two: A B C D LODGING RESERVATIONS Please reserve accommodations at Hyatt Regency Maui Resort & Spa for: #1471 Arrival: / / Departure: / / Month Day Year Month Day Year GROUP RATES are for single/double occupancy and INCLUDE DAILY BUFFET BREAKFAST: TYPE OF ROOM Golf Mountain View Partial Ocean View Deluxe Ocean View Deluxe Ocean Front GROUP RATES $270/night $320/night $360/night $400/night Conference group rates are per room, per night and do not include the following (subject to change): % state & local taxes - $15 (plus 4.166% tax) resort fee (discounted from $32) - $12 (plus 4.166% tax) per person (regardless of age), roundtrip porterage (bellman) fee Maximum guestroom occupancy is four, regardless of age (5 th guest allowed if it is an infant under 12 months old, subject to crib rental fee, if needed) Mandatory additional person charges (below) include daily buffet breakfast, taxes, and gratuities: - Children 4 years and under are FREE - Children 5 to 12 years old are $16/person, per night - Children 13 to 18 years old are $36/person, per night - Adults 19 years and older are $86/person, per night Rollaways & Cribs: Rollaway beds and cribs are $25 each, per night (based on availability and subject to change). Only one crib or one rollaway is allowed in each room. Preferred Bed Type (cannot guarantee): One Bed Two Beds Names of Room Occupants (and ages, if children): Please circle names of the room occupants (other than you) who are registered for this conference Other Comments/Requests (cannot guarantee): TUITION AMOUNT DUE TWO NIGHTS LODGING DEPOSIT - ROOM RATE ONLY (Balance of hotel charges will be due to the hotel) ADDITIONAL LODGING DEPOSIT (If you wish to include an additional amount for lodging, please state here) $ $ $ $ TOTAL Payment Type (Please Check One): Check (Please Enclose) Cardholder Name: Signature: First Last Billing Address: (If different from above) Street City State Zip Card Number Expiration Date Month/Year / Security # (on front or back of card) By registering, you agree to the Terms & Conditions as stated in this brochure. Please note that all information contained in this brochure is subject to change without notice. ALL INFORMATION PROVIDED BY REGISTRANTS WILL REMAIN CONFIDENTIAL TO SYMPOSIA MEDICUS. Page 63 Conference Brochure #1471, 26 th Annual Fall Conference on Issues in Women s Health Symposia Medicus