2014 Ambulatory Care Conference and Summit
March 3–4, 2014 | The Westin Galleria Dallas | Dallas, Texas
Register in advance and SAVE! Register at www.ashp.org/ambulatorycareconference14
Early Bird Deadline: January 17, 2014 (Rates increase January 18, 2014)
Premeeting Registration Deadline: February 14, 2014
Please provide home and business information and check preferred address for correspondence.
ASHP ID Number (if applicable):____________________ Name______________________________________________
Title: ________________________________________ Name for Badge:______________________________________
Daytime Phone: ________________________________ Fax:_______________________________________________
E-mail (required for meeting confirmation):______________________________________________________________
q Additional tax-deductible donation to the
ASHP Research and Education Foundation
q A Director
q B Associate or Assistant Director
q C Clinical Coordinator
q D Other Supervisory Position
q E Staff Pharmacist
q F Clinical Pharmacist–General
q G Clinical Pharmacist–Specialist
q H Faculty
q I Student
q J Resident
q K Technician
q N Other:
METHOD OF PAYMENT
Please check one.
q Members (Early Bird–before Jan. 17)
q Non-Members (Early Bird–Before Jan. 17)
q Members (After Jan. 18)
q Non-Members (After Jan. 18)
q One Day Member
q One Day Non-Member
q Resident/Student/Tech Members
q Resident/Student/Tech Non-Members
What is your primary position?
(please check one)
TOTAL FEES $
Breakfasts (2), Lunches (2), and a Reception.
q Enclosed is my check or money order made payable to ASHP
and drawn on a U.S. Bank.
q Enclosed is my U.S. purchase order number #_________.
Please issue invoice.
q Charge $______ to my: q MasterCard q VISA q AmEx q Discover
Card #: __________________________________ Exp. Date: _________
y authorizing this charge, I certify that the above registration information
is true and correct, and agree to be responsible for any additional charges.
FOUR WAYS TO REGISTER
q ONLINE www.ashp.org/ambulatorycarconference14
(It’s the quick and easy way to go!)
BREAkOUT SESSIONS: Please select one each day
Monday, March 3, 2014 I 2:00 p.m.–5:00 p.m. (3 hours in duration)
q CALL TOLL-FREE 1-866-279-0681, Mon.–Fri. 8 a.m.–6 p.m. EST
q Breakout 1: (BK1A) It Starts with Us: Defining Ambulatory Care
q FAX registration form to 1-301-657-1251
q Breakout 2: (BK2A) Navigating the Future: Patient Care Delivery and
q MAIL registration form with check or money order payable to ASHP.
Checks must be drawn on a U.S. bank in U.S. funds.
ASHP Payment Center, P.O. Box 17693, Baltimore, MD 21297
q Breakout 3: (BK3A) Develop the Possibilities: Sustainable Business
q Breakout 4: (BK4A) Make It Matter: Outcomes Evaluation
Tuesday, March 4, 2014 I 9:20 a.m.–12:20 p.m. (3 hours in duration)
q Breakout 1: (BK1B) It Starts with Us: Defining Ambulatory Care
q Breakout 2: (BK2B) Navigating the Future: Patient Care Delivery and
q Breakout 3: (BK3B) Develop the Possibilities: Sustainable Business
q Breakout 4: (BK4B) Make It Matter: Outcomes Evaluation
Registration Cancellation and refunds
To receive a full-meeting registration refund, confirmed registrations
must be cancelled in writing and mailed or faxed on or before
February 14, 2014 (postmark or fax date). Written cancellations
postmarked or faxed February 15 through March 2 will be subject
to a $50 handling charge. Refunds will be issued only for cancellations
postmarked or faxed before March 3.
ARRANGEMENTS FOR SPECIAL ASSISTANCE
If you have any disability for which you may require an auxiliary aid
or special service while attending this meeting, please contact:
Jessica Cremer at ASHP, 301-664-8616
Please Note: Payments to ASHP are not deductible as charitable contributions for federal income tax purposes. However, they may be deductible under other provisions of the Internal
Revenue Code. Only additional donations to the ASHP Research and Education Foundation are tax deductible.