Ideal Medical Practice 2009 Camp
University of Washington
Seattle, WA 

August 14-15, 2009

Register


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Registration includes Friday lunch and dinner, Saturday breakfast and lunch, and snacks.  

Regular Registration (on or after May 1):  $200

Online registration will close on August 10, 2009 at 5:00 PST.

Payment options include check or credit card.

* First Name:

* Last Name:

Practice Name:

* Practice Address:

Address cont'd:

* City:

 * State:

* Zip Code:

* Practice Phone:

Cell Phone:

Website:

* E-mail:

   

Conference attendee information will be given to attendees for contact during the meeting. If you do not want your information released please check this box: 
 

Scholarship:  Please check if you need help with conference expenses.


*Friday Night Banquet:

This is included in the Camp registration fee.  Additional guest tickets are $30.  How many people (including friends/family) will be attending?

 


*Saturday Evening BBQ and Party:

This not included in the Camp registration fee. Tickets are $30.  How many people (including friends/family) will be attending? 

 


Camp 2008 Video/Audio Presentations:

Registrants will receive some Camp pre-work to review before Camp (a few articles to read, etc).  If you would like a copy of the video/audio presentations from last year’s camp to review please check this box:

If you attended last year’s camp, there is no charge; if you were not able to make it, there is a $12 fee.


Your Practice:

I am:

a primary care medical provider (physician or nurse practitioner)
an IMP doctor's team member

Specialty: 

                 Other: 

Years in practice post-residency: 

Team Role:    Other:

EMR: Other


Ideal Medical Practice:

Have you participated in an IMP cohort? Yes No

Do you use HowsYourHealth with your patients? Yes No

If contemplating an IMP:

When do you anticipate opening?

Describe your current practice:

If doing an IMP already:

How many years in IMP? 

How many FTE providers are in your practice?   

How many staff? 

What would you like help with?


Special Dietary Restrictions:


Questions/Comments:


Acceptance of Terms and Conditions

I have reviewed and acknowledge acceptance of the terms and conditions which includes the cancellation policy, insufficient check funds policy, and credit card terms.

 
*   

Payment options include: Check or credit card

If you would like a copy of this completed form, please print this page before you select "continue" and continue with the payment process.