Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 1 Registration & Housing REGISTER, RESERVE A HOTEL & BOOK COURSES BADGE/NAME INFORMATION Member/Customer ID Number Name* Middle Initial/Name Last/Family Name* Badge First Name Business Name* Department Job Title NPI NUMBER In an effort to assist our industry partners’ compliance with the mandatory reporting provisions of the Sunshine Act, which require electronic disclosure of any “payment or other transfer of value given to a physician” to the Department of Health and Human Services, HRS is requesting that U.S. physician attendees provide their National Provider (NPI) number when registering for HR2013. For more information, please visit the Centers for Medicaid and Medicare Services website at www.cms.gov MAILING INFORMATION ❑ Home OR ❑ Business Street Address* Street Address 2/Building or Suite Number City* State/Province* Zip/Postal Code* Country* Phone (Day Time)* (country code/city code/number) Mobile Phone (country code/city code/number) Fax (country code/city code/number) Email* EMERGENCY CONTACT INFORMATION Emergency Contact’s First Name* Emergency Contact’s Last/Family Name* Emergency Contact’s Day Time Phone (country code/city code/number)* ❑ Third Party Mailings Opt Out Check this box to opt out of providing your contact information to exhibitors. If you do not check this box, your contact information will be provided to Heart Rhythm 2013 exhibiting companies so they may present you with information on related products and services by way of mail. ❑ Heart Rhythm 2013 – Communicate Check this box to opt-out of Heart Rhythm 2013 – Communicate. This social networking feature allows Heart Rhythm 2013 registrants to search and contact other registered colleagues before and during the Sessions. The feature will enable communications via e-mail, but your e-mail address will not be disclosed to other registrants. All e-mails will remain Exhibiting companies will not have access to this feature. ❑ Special Services Check here if you require special services. Please describe special services: ______________________________________________________ ________________________________________________________________________________ HRSonline.org/Sessions Fax completed registration form with credit card information to 508-743-9636 Mail completed registration forms with full payment to: Heart Rhythm 2013 c/o Convention Data Services 107 Waterhouse Road Bourne, MA 02532 800-748-5052 508-743-0529 SOURCE CODE INFORMATION ____________________________________ Please enter above the Code found on your promotional mailing or email.* Or How did you hear about Heart Rhythm 2013? ❑ Advertisement in HeartRhythm Journal ❑ Advertisement – print publication ❑ Advertisement – website other than HRS ❑ Advance Program ❑ Email Announcement ❑ Facebook ❑ Heart Rhythm Society Website ❑ Professional Conference ❑ Twitter ❑ Word of Mouth ❑ Other _________________ From where did you get additional information about Heart Rhythm 2013? (Check all that apply) ❑ Advertisement in HeartRhythm Journal ❑ Advertisement – print publication ❑ Advertisement – website other than HRS ❑ Advance Program ❑ Email Announcement ❑ Facebook ❑ Heart Rhythm Society Website ❑ Professional Conference ❑ Twitter ❑ Word of Mouth ❑ Other _________________ SPECIAL DIETARY NEEDS (Leave blank if not applicable) ❑ Kosher ❑ Vegetarian Please note: Kosher meals must be requested by May 1, 2013.
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Heart Rhythm Society – 34th Annual Scientific Sessions 2013
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Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 1
Registration & HousingREGISTER, RESERVE A HOTEL & BOOK COURSES
BADGE/NAME INFORMATION
Member/Customer ID Number
Name* Middle Initial/Name Last/Family Name*
Badge First Name
Business Name*
Department Job Title
NPI NUMBER In an effort to assist our industry partners’ compliance with the mandatory reporting provisions of the Sunshine Act, which require
electronic disclosure of any “payment or other transfer of value given to a physician” to the Department of Health and Human Services, HRS is requesting that U.S. physician attendees provide their National Provider (NPI) number when registering for HR2013. For more information, please visit the Centers for Medicaid and Medicare Services website at www.cms.gov
MAILING INFORMATION ❑ Home OR ❑ Business
Street Address*
Street Address 2/Building or Suite Number
City* State/Province* Zip/Postal Code* Country*
Phone (Day Time)* (country code/city code/number)
Mobile Phone (country code/city code/number) Fax (country code/city code/number)
Email*
EMERGENCY CONTACT INFORMATION
Emergency Contact’s First Name* Emergency Contact’s Last/Family Name*
Emergency Contact’s Day Time Phone (country code/city code/number)*
❑ Third Party Mailings Opt Out Check this box to opt out of providing your contact information to exhibitors. If you do not check this box, your contact information will be provided to Heart Rhythm 2013 exhibiting companies so they may present you with information on related products and services by way of mail.
❑ Heart Rhythm 2013 – Communicate Check this box to opt-out of Heart Rhythm 2013 – Communicate. This social networking feature allows Heart Rhythm 2013 registrants to search and contact other registered colleagues before and during the Sessions. The feature will enable communications via e-mail, but your e-mail address will not be disclosed to other registrants. All e-mails will remain Exhibiting companies will not have access to this feature.
❑ Special Services Check here if you require special services. Please describe special services: ______________________________________________________
Fax completed registration form with credit card information to 508-743-9636
Mail completed registration forms with full payment to:Heart Rhythm 2013c/o Convention Data Services107 Waterhouse RoadBourne, MA 02532
800-748-5052508-743-0529
SOURCE CODE INFORMATION
____________________________________Please enter above the Code found on your promotional mailing or email.*
Or
How did you hear about Heart Rhythm 2013?
❑ Advertisement in HeartRhythm Journal❑ Advertisement – print publication❑ Advertisement – website other than HRS❑ Advance Program❑ Email Announcement❑ Facebook❑ Heart Rhythm Society Website❑ Professional Conference❑ Twitter❑ Word of Mouth❑ Other _________________
From where did you get additional information about Heart Rhythm 2013? (Check all that apply)
❑ Advertisement in HeartRhythm Journal❑ Advertisement – print publication❑ Advertisement – website other than HRS❑ Advance Program❑ Email Announcement❑ Facebook❑ Heart Rhythm Society Website❑ Professional Conference❑ Twitter❑ Word of Mouth❑ Other _________________
SPECIAL DIETARY NEEDS(Leave blank if not applicable)
❑ Kosher❑ VegetarianPlease note: Kosher meals must be requested by May 1, 2013.
Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 2
Registrantname: _____________________________
HEART RHYTHM 2013 SCIENTIFIC SESSIONS FEE CATEGORIESTheregistrationfeeforHeartRhythm2013includesadmissiontotheMini-Courses,AlliedProfes-sionalsForums,Basic/TranslationalScienceForum,LeadManagementForum,Hands-OnSession,OpeningPlenarySession,Case-BasedTutorials,CoreCurricula,Oral/Poster/ModeratedAbstractPresentationsandFeaturedSymposia,Debates,TranslationalEPSessions,TechnicalExhibits,FeaturedPostersSessionandReception,andtheAwardsCeremonyandPresidents’Reception. An additional feeisrequiredfortheAFSummit,VT/VFSummit,Meet-the-ExpertLuncheons,andtheWomeninEPNetworkingLuncheon.(See descriptions and requirements online at www.HRSonline.org)
ONE-DAY REGISTRATIONTheone-dayregistrationfeeincludesadmissiontothenon-ticketedsessionsandTechnicalExhibitsheldonthedayofregistrationonly.TheWednesdayfeeincludestheTechnicalExhibitsanddoesnotincludetheAFSummitortheVT/VFSummit.TheSaturdayfeedoesnotincludetheTechnicalExhibits.Ticketedfunctionswithfeesareextraforall registrants. (Chose one day only.)
8. Date of Birth* _________/________/_________ (Month/Day/Year)
Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 3
TICKETED FUNCTIONS (FEE REQUIRED)REGISTER EARLY! SPACE IS LIMITED!Byselectingticketedfunctionsbelow,youwillbeissuedaticketforeachfunction.AFullScientificSessionsRegistrationoraOne-DayregistrationisrequiredtobeeligibletoselecttheMeet-the-ExpertLuncheonsandtheWomeninEPNetworkingLuncheon.
AF SummitWednesday, May 8, 8 a.m. – 4 p.m. You may select the AF Summit alone or in conjunction with your Scientific Sessions Registration.q AF Summit with Full Registration (Physician/Industry/Scientist/
Emeritus Members), $335q AF Summit with Full Registration (Allied Health Professional,
including Physician Assistant and Hospital Administrator Members), $135
q AFSummitwithFullRegistration(AffiliateMembers),Complimentaryq AF Summit with Full Registration (Physician/Industry/Scientist/
q AF Summit with Full Registration (Allied Health Professional, Physician Assistant, Hospital Administrator, and Undergraduate StudentNon-members),$235
q AFSummitonly(Fellows-orScientists-in-Training/AlliedHealthProfessionals, including Physician Assistant and Hospital Administrator, and Undergraduate Student Nonmembers), $395
VT/VF SummitWednesday, May 8, 8 a.m. – 4 p.m. You may select the VT/VF Summit alone or in conjunction with your Scientific Sessions Registration.q VT/VFSummitwithFullRegistration(Physician/Industry/Scientist/
Women in EP Networking LuncheonPlease select if you plan on attending.Friday, May 10, 12:15 – 1:15 p.m.q Members: $65 qNon-members:$85
FUNCTIONS THAT REQUIRE ADVANCE SELECTIONThefollowingfunctionsareincludedwithyourScientificSessionsregistration. However, to assist us in determining the appropriate room size,pleaseselectthefunctionsyouplantoattend.Aticketwillnotbeissuedtoattendthesefunctions.Seatingwillbeavailableonafirst-come,first-servedbasis.AFullScientificSessionsRegistrationoraOne-Dayregistrationisrequiredtoattendthesefunctions.
Mini-Courses Wednesday, May 8See the Advance Program or visit www.HRSonline.orgforacompletelistingofMini-Courses(MC)(spaceislimited;indicatechoicesbyMCnumber).q 8 – 11 a.m. 1stchoice(MC)____ 2nd(MC)____ 3rd(MC)____q 1 – 4 p.m. 1stchoice(MC)____ 2nd(MC)____ 3rd(MC)____
Allied Professionals Forum I: Introduction to EP for the Novice Allied ProfessionalsAuniqueone-dayprogramfocusingonfundamentalsfortheAlliedHealthProfessionalnewtothefieldandtheHands-OnEducationSession.q Wednesday, May 8, 8 a.m. – 3:30 p.m.
Allied Professionals Forum II: Introduction of Device Therapies for the Novice Allied ProfessionalsAuniqueone-dayprogramfocusingonfundamentalsfortheAlliedHealthProfessionalnewtothefieldandtheHands-OnEducationSession.q Wednesday, May 8, 8 a.m. – 3:30 p.m.
Allied Professionals Forum III: Insights into Managing Complex Arrhythmia and Device Patients for the Advanced Allied ProfessionalsAuniqueone-dayprogramfocusingonadvancedcontentfortheexperiencedAlliedHealthProfessional.q Wednesday, May 8, 8 a.m. – 4 p.m.
Basic/Translational Science Forum: Heart Rhythm Systems PhysiologyPresentedinpartnershipwiththeCardiacElectrophysiologySociety(CES),theforumwillprovideanopportunityforthepresentationanddialogueaboutnewresearchandscience.q Wednesday, May 8, 8 a.m. – 4 p.m.
Registrantname: _____________________________
Heart Rhythm 2013 Registration and Housing Form Register today, visit HRSonline.org/Sessions 4
Lead Management Forumq Wednesday, May 8, 8 a.m. – 4 p.m.
Society Leadership Lunch Forumq Wednesday, May 8, noon - 1 p.m.
Featured Poster Session and ReceptionIncludedintheScientificSessionsregistration,Wednesday-only,andguest registrations. Please select if you plan on attending.q Wednesday, May 8, 6 – 7:30 p.m.
Awards Ceremony & Presidents’ ReceptionIncludedintheScientificSessionsregistration,Friday-only,andguestregistrations. Please select if you plan on attending.q Friday, May 10, 6 – 7:45 p.m.
Final Program Bookq Yes,IwouldliketoreceiveaprintversionoftheFinalProgram.A
Hotel Choices(SeetheAdvance Program or www.HRSonline.org/ Sessionsforlisting;listchoicesinorderofpreference):Choiceisbasedon:q Priceq Location1. ______________________________________________2. ______________________________________________3. ______________________________________________4. ______________________________________________
Special Requests: (Subject to availability)q NonsmokingRoomq Ihaveadisabilitythatwillrequireaccommodationq King Bedq ConciergeLevelq FrequentStayProgramNameandIDNumber:____________________________________________________________________________
Please note:Hotelroomsarelimited.Ifnoneofmychoicesareavail-able,pleasecheckoneofthefollowing:q Do not assign me a room.q Assign me a room at any available hotel.q Assignmearoomatahotelwithasimilarprice.q Assignmearoomatahotelinasimilarlocation.Adepositofonenight’sroomandtaxbyassignedhotelatapplicablerateisrequired.CreditcardswillbechargedonoraroundApril6,2013.
PAYMENT & PROCESSING OF FEES
TOTAL PAYMENT FOR REGISTRATION, FEE-BASED FUNCTIONS, and OTHER RELATED PRODUCTS = $______________Creditcardsarebilledimmediatelyuponreceiptofregistrationform.Checks/MoneyordersmustbeinU.S.fundsanddrawnonaU.S.bank.Checks/MoneyordersmustbemadepayabletoHeart Rhythm Society.
CreditCard:q MasterCard q VISA q AmericanExpress
Card Number
ExpirationDate(MM/YY)
PrintCardholder’sName
Cardholder’sSignature
Refundrequestsmustbesubmittedinwriting(nophonecalls,please)toCDSandreceivedby5p.m.EDT,April12,2013.A$75processingfeewill be withheld.
Register today, visit www.HRSonline.org/Sessions
TOTAL PAYMENT FOR HOTEL = $______________CreditcarddepositwillbebilledonoraroundApril6,2013.