Surgeon Profile Form

Glaucoma Today is proud to present didactic Canaloplasty courses for ophthalmologists and technicians via support from iScience Interventional.

We encourage you to complete the below surgeon profile form to begin the registration process. We will contact you to confirm your registration.

For more information, please email EducationalTraining@bmctoday.com.

First

Last

Street

City

State

Zip

Phone Number

Specialty (check one)			Glaucoma
			Cataract
			Refractive

Practice Type (check one)			Solo Practitioner
			Multi-Practitioner
			Multi-Specialty

Medical School Attended

Fellowship location

Please answer the following questions thoroughly and check all that apply:

Approximately how many ophthalmic procedures do you perform on a monthly basis:

		Trabeculectomy				Viscocanalostomy
		Deep Sclerectomy				Drainage implant
		Cataract				ALT/SLT

Penetrating surgery experience:

Less than 1 yr.

1-2 yrs.

3+ yrs.

Nonpenetrating surgery experience:

Less than 1 yr.

1-2 yrs.

3+ yrs.

Previous Viscocanalostomy experience:

Yes

Glaucoma surgery procedure location:

ASC

Hospital

Previous attendance of a
nonpenetrating training course:

Yes

Referral network/sources:
(check those applicable)

Practice partners

OD's

Primary care

How did you learn
of this program?

At which location would you like to attend the course?
Please select multiple cities in ranking order and you will be contacted on your placement.

		Saturday, March 7, 2009 Manchester Grand Hyatt One Market Place San Diego, California 92101 Phone: (619) 232-1234 1 to 3pm, Didactic Session Course Chairs Howard Barnebey, MD Richard Lehrer, MD				Future Courses Locations and Dates coming soon!