REGISTRATION FORM
AAFP Family Medicine Experience (FMX)
Orange County Convention Center • Orlando, FL • Tuesday, September 20–Saturday, September 24, 2016
Register online at
www.aafp.org/fmx
Please print the following information:
AAFP ID # (if applicable):____________________________________________________________________
Name: ___________________________________________________________________________________
Advance Deadline
August 17
Nickname for badge: _______________________________________________________________________
Degree:__________________________________________________________________________________
Address: _________________________________________________________________________________
City, State, Country, Zip: ____________________________________________________________________
Business Phone: __________________________________________________________________________
Fax:_____________________________________________________________________________________
F
NEW!
Registration fee includes FMX
On Demand, an online library
with 25 hours of CME-eligible
sessions from FMX (a value of
$775). Earn up to 32.75 Live
and 25 Enduring CME credits.
Email (for confirmation):_____________________________________________________________________
Emergency Contact Name:__________________________________________________________________
Emergency Contact Phone #:________________________________________________________________
Part I – Registration Fee
FMX Fee Schedule
Check
appropriate
box
Registration
category
All
2016 FMX meeting
materials, badges, tickets,
and promotional mailings
from exhibitors will be mailed
to this address.
Opt-out Options
You can opt out of receiving promotional
mailings from exhibitors and sponsors
of satellite event activities. You can
choose to not include your email address
in your contact information shared with
exhibitors you visit. And, you can opt to
not include your name, city, and state
from the attendee list:
Received by
August 17
After August 17
on-site fees apply
AAFP Member
(Active, International, Supporting)
$795
$895
AAFP New Physician Member
$745
$845
AAFP Life Member
AAFP Inactive Member
Resident
Student
$100
$100
[ 960] I do not wish to receive promotional
postal mailings from exhibitors before and
after FMX.
Allied Health Professional (RN, NP, PA, etc.)
$945
$1,045
Physician Nonmember
$1,145
$1,245
[ 961] I do not wish to receive promotional
postal mailings from sponsors of satellite
activities/events before and after FMX.
$0
$0
Chapter Executive
Chapter Staff
Discount code (if applicable): ____________________
Total Amount Due from Part I: $_____________
[962] Do not provide my email address to
exhibitors I visit.
[963] Do not include my name, city, state,
residency program, and AAFP Member Interest
Group(s) in the FMX attendee list published in
the mobile app and on the website.
continued ...
2016 FMX REGISTRATION FORM PAGE 2
Part II — Extra-fee CME
Clinical Procedural Workshops
— FMX offers hands-on clinical procedural courses presented by expert faculty. At least 50 percent
of course time is devoted to practicing skills. Separate fee and registration required. Individual course descriptions and ticket policies can be found
online at www.aafp.org/fmx. Due to the limited number of seats, please indicate your time preference for each course you would like to attend.
Check
appropriate box
Session
Number
CME400
2015 FMX Procedures
Price
Acne Treatment and Procedures
$320
Acupuncture & Manipulation Techniques for Pain Management
$240
CME405
Aesthetic Dermal Filler Injections for Facial Rejuvenation
$240
CME406
Cosmetic Botulinum Toxin Injections (Advanced)
$160
Cosmetic Botulinum Toxin Injections (Fundamentals)
$160
Dermoscopy With Online Module
CME401
CME402
CME403
CME404
CME407
CME408
CME409
CME414
CME415
CME416
8 a.m.–12 p.m.
Wed
8:30–11:30 a.m.
Wed
2–5 p.m.
Thur
8:30–11:30 a.m.
Wed
9 a.m.–12 p.m.
Fri
1–3 p.m.
Thurs
9–11 a.m.
2–4 p.m.
8–11 a.m.
Wed
1–4 p.m.
Dermoscopy
$240
Thurs
8–11 a.m.
ECG Analysis (Advanced)
$320
ECG Analysis (Fundamentals)
$320
Electrosurgery and Cryosurgery
$240
Introduction to Musculoskeletal Ultrasound and Guided Injections
$240
CME419
CME420
CME421
8 a.m.–12 p.m.
Sat
CME417
CME418
Fri
Sat
$240
CME412
CME413
Time
Thurs
CME410
CME411
Day
Long-Acting Reversible Contraceptives (LARC)
$240
Thurs
1–4 p.m.
Fri
1:30–5:30 p.m.
Wed
8 a.m.–12 p.m.
Thurs
1:30–5:30 p.m.
Fri
1–4 p.m.
Fri
8–11 a.m.
Fri
1–4 p.m.
Sat
8–11 a.m.
Wed
8:30–11:30 a.m.
Wed
1:30–4:30 p.m.
Thurs
8:30–11:30 a.m.
CME423
Wed
8–11 a.m.
CME424
Wed
1–4 p.m.
Thurs
8–11 a.m.
CME425
Fri
8–11 a.m.
CME426
Fri
1–4 p.m.
CME422
CME427
Musculoskeletal Injections
$240
CME428
CME429
Nail Procedures
$160
CME430
CME431
CME432
CME433
CME434
CME435
CME436
CME437
Sideline Management Assessment Response Techniques (SMART)
Soft Tissue Surgery (Advanced)
$320
$320
Soft Tissue Surgery (Fundamentals)
$320
Splinting, Casting, Wrapping, and Taping
$320
Thurs
2–4 p.m.
Fri
9–11 a.m.
Sat
9–11 a.m.
Fri
1–5 p.m.
Wed
1–5 p.m.
Thurs
1–5 p.m.
Wed
8 a.m.–12 p.m.
Thurs
8 a.m.–12 p.m.
Thurs
8 a.m.–12 p.m.
Thurs
1–5 p.m.
Rank times by
Preference
If faxing, please include name and daytime phone number: _______________________________________________________________________________________
2016 FMX REGISTRATION FORM PAGE 3
Part II — Extra-fee CME continued
Check
box
Out & Abouts
Learners will have the opportunity to participate in the experiential
learning format, known as an Out & About. This format takes learners
out of the traditional session at the convention center, and provides a
unique environment for hands-on learning that encourages improved
outcomes through increased awareness, earlier and more accurate
diagnosis, prompt intervention, and individualized long-term management. Course descriptions can be found online at www.aafp.org/fmx.
Total Amount Due from Part II: $ _________
Part III – FMX Celebration–Friday, September 23
Back by popular demand! We’ve reserved the entire Universal’s Islands of
Adventure® theme park just for you! You’ll have unlimited access to incredible rides,
arcades and attractions like The Amazing Adventures of Spider-Man®, Jurassic
Park River Adventure®, and the magic and excitement of The Wizarding World of
Harry Potter™. It’s an entire universe of action and thrills—and it’s all yours for the
night! HARRY POTTER, characters, names and related india are trademarks of and
© Warner Bros. Entertainment, Inc. Harry Potter Publishing Rights © JKR. Marvel
Super Hero character names and likenesses: TM & © 2010 Marvel © 2010 Universal
Studios, Jurassic Park River Adventure, Jurassic Park ® University Studios/Amblin.
Session
Number
CME450
CME451
CME452
CME453
CME454
Day/Time
Name
Price
Wed., Sept. 21
7:15 a.m.–12:30 p.m.
Thurs., Sept. 22
7:15 a.m.–12:30 p.m.
Fri., Sept. 23
7:15 a.m.–12:30 p.m.
Thurs., Sept. 22
7:15 a.m.–12:30 p.m.
Fri., Sept. 23
7:15 a.m.–12:30 p.m.
Out & About:
Adolescent Sports Injury,
Concussion & Office
Emergency Simulation
Out & About: ACLS
Update and Resuscitation
of the Hypovolemic
Patient Simulation
$260
$260
$260
$260
$260
Universal Islands of Adventure – 7 to 11 p.m.
Number
of tickets
(Max 1)
Session
Number
Ticket Type
Price
Total Cost
935
Attendee
$0
$0
936
Guest Ticket
Ages 4 and up
$50
$
*Children 3 and younger are free and do not require a ticket.
Your registration includes one ticket to the event. (You must select #935 above)
Total Amount Due from Part III: $ _________
Part IV – AAFP Foundation VIP Benefit Friday, September 23 • 5:30 p.m.
Join us for dinner and rum pairings as you pass through the doors of the Cuba
Libre Restaurant & Rum Bar. You will be transported to an Old Havana courtyard complete with exotic tropical foliage and vintage decor. Chef Guillermo
Pernot will prepare a delectable menu of classic & contemporary Cuban cuisine. You might even learn how to make a Mojito and salsa dance with a pro
while you are there. Restaurant is in walking distance of the headquarters hotel.
Number
of tickets
Session
Number
Name
Price
943
AAFP Foundation
VIP Benefit (includes
dinner, Islands of
Adventure ticket and
VIP tour)
$300
Total Cost
$
The AAFP has reserved the entire Universal’s Islands of Adventure® theme
park just for FMX attendees! But your AAFP Foundation has gone one step
further. Experience Universal’s Islands of Adventure® as only a VIP can. Those
wanting to experience the Islands of Adventure will depart the Cuba Libre via a shuttle and those wanting to stay can enjoy the rest of their evening at
the Cuba Libre Restaurant and Rum Bar. VIP Tour guests will enjoy a guided walking tour of the park, exclusive information, and priority entrance into
major rides/attractions as your guide escorts you throughout the park. The tours will be tailored to your group so you can enjoy the specific attractions
that appeal to you.
Total Amount Due from Part IV: $ _________
Part V – AAFP Member Interest Groups
The AAFP is committed to helping you network with colleagues who have
common interests. Learn more about the member interest groups (MIGs)
at the MIG reception on Thursday, September 22, at the Orange County
Convention Center. And, don’t miss the chance to share experiences and
discuss and set goals for the MIGs at their annual meetings. Mark the MIG
topic(s) that you would like to follow, and the AAFP will make sure you
know where to meet up with your colleagues during FMX.
Session Number
965
966
967
968
969
970
971
972
973
974
975
976
977
Interest
Direct Primary Care
Emergency Medicine/Urgent Care
Global Health
Hospital Medicine
Independent Solo/Small Group Practice
Oral Health
Reproductive Health Care
Rural Health
School Doctor
Single Payer Health Care
Telehealth
Transforming Clinical Practice Initiative (TCPI)
Adolescent Health
If faxing, please include name and daytime phone number: _______________________________________________________________________________________
2016 FMX REGISTRATION FORM PAGE 4
Part VI — City Tours
Individual tour descriptions and restrictions can be found online at www.aafp.org/fmx. All city tours will depart and return to the Orange County
Convention Center. Please arrive for your tour 15 minutes prior to the departure time.
Tour Name
Session
Number
901
Price On or Before
Aug. 17/After Aug. 17
Airboat Adventure & Nature Trail
$132/$152
903
Winter Park Scenic Boat and Shopping Tour Adult Ticket
$76/$96
904
Winter Park Scenic Boat and Shopping Tour (ages 14 and under)
$68/$88
Truffles & Trifles Cooking Class
$157/$177
902
905
906
Day
Rank Times by
Preference
Time
Total Cost
Tues
1–5 p.m.
$
Wed
8 a.m.–12 p.m.
$
Wed
12–6 p.m.
$
Wed
12–6 p.m.
$
Fri
1–5 p.m.
$
Wed
5–9 p.m.
$
907
Showcase of Citrus Adult Ticket
$99/$119
Fri
8 a.m.–12 p.m.
$
908
Showcase of Citrus (ages 12 and under)
$83/$103
Fri
8 a.m.–12 p.m.
$
909
Eco-Safari Zipline
$188/$199
Thurs
8 a.m.–1 p.m.
$
910
Kennedy Space Center Adult Ticket
$135/$145
Wed
8 a.m.–4 p.m.
$
911
Kennedy Space Center (ages 12 and under)
$125/$135
Wed
8 a.m.–4 p.m.
$
912
Kennedy Space Center Adult Ticket
$135/$145
Thurs
8 a.m.–4 p.m.
$
913
Kennedy Space Center (ages 12 and under)
$125/$135
Thurs
8 a.m.–4 p.m.
$
914
Culinary Tour of Orlando
$309/$329
Tues
4–9 p.m.
$
Private Deep Sea Fishing Charter
$360/$370
915
916
Wed
8 a.m.–3 p.m.
$
Thurs
8 a.m.–3 p.m.
$
917
Indian River Kayaking
$113/$123
Fri
8 a.m.–1 p.m.
$
918
Stand up Paddle Boarding
$99/$129
Thurs
1–5 p.m.
$
Total Amount Due from Part VI: $ _________
Part VII – AAFP Foundation Lapel Pin
Get your 2016 FMX Commemorative Lapel Pin and support your AAFP
Foundation. For a minimum donation, you can support AAFP Foundation
programs, such as Family Medicine Cares, which helps to support
underserved populations.
Quantity
of Lapel
Pins
Session
Number
Name
Price
945
AAFP Foundation
Lapel Pin
$15
Total Cost
$
Total Amount Due from Part VII: $ _________
Part IX – Guest Registration
The AAFP considers your family or significant other to be your guest (limited to four). Additional guests may be added on site for a $25
administrative fee. Office personnel/staff must register as Allied Health Professional attendees. Guest attendees cannot attend, purchase,
or report CME events/hours. Out of consideration of others, please do not bring children to CME events.
1. _____________________________________________________________________________________
2._____________________________________________________________________________________
3._____________________________________________________________________________________
4._____________________________________________________________________________________
If faxing, please include name and daytime phone number: _______________________________________________________________________________________
2016 FMX REGISTRATION FORM PAGE 5
CANCELLATION POLICY:
The AAFP must receive notice of cancellation by
August 30, 2016. Requests for full cancellation will
be refunded less a $50 administrative fee. To view
the complete cancellation policy, please visit
www.aafp.org/fmx.
Part IX – Total Registration
Total amount due from Part I $____________________
Total amount due from Part II $____________________
Total amount due from Part III $____________________
SPECIAL ASSISTANCE
Wheelchair/Scooter Rentals
If you need help getting around the convention center, you may order a scooter
in advance of the meeting for an additional fee. Visit www.aafp.org/fmx for more
information.
Total amount due from Part IV $____________________
Total amount due from Part VI $____________________
Additional Needs
If you or a guest needs hearing or vision assistance in order to participate fully
in FMX activities, please let us know at least two weeks in advance.
Total amount due from Part VII $____________________
Contact us: (800) 274-2237, (913) 906-6000, or [email protected].
PHOTOGRAPHY AND RECORDING
The AAFP may take photographs and/or record audio and video at this
event. By attending, you consent to the use of photographs, audio, and video
recordings of you by the AAFP and its designees in AAFP communications and
promotions, or for any other lawful purpose.
Total amount enclosed $____________________
Part X – Method of Payment
To expedite registration processing, credit card payment is preferred. Please print clearly to avoid delay in processing your registration. Registration
forms will be accepted only when accompanied by full payment.
MasterCard
Visa
American Express
Discover
Check Enclosed
Card Number:_______________________________________________________________________________________________________________________
Exp. Date:__________________________________________________________________________________________________________________________
Cardholder Name:___________________________________________________________________________________________________________________
Please print
Signature:__________________________________________________________________________________________________________________________
Credit Card: Your signature above authorizes the AAFP to charge your credit card for the total amount above. If your registration fees are totaled incorrectly,
the AAFP will make the necessary adjustments and charge your credit card accordingly. Fax to (913) 906-6075
Check: Please make payable to the American Academy of Family Physicians, drawn on a U.S. Bank in U.S. Dollars, and return to:
AAFP Member Resource Center
11400 Tomahawk Creek Parkway
Leawood, KS 66211-2680
If faxing, please include name and daytime phone number: _______________________________________________________________________________________