ACP South Dakota Chapter Annual Meeting


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ACP South Dakota Chapter Annual Meeting

  1. 1. SOUTH DAKOTA ACP SCIENTIFIC MEETING2012 BEST WESTERN RAMKOTA September 12-14 Sioux Falls, SDTop: Falls Park ---- Right: David by Michaelangelo ---- Bottom: Ramkota 

  2. 2. PROGRAM SCHEDULE:Wednesday,       4:00  -­‐  6:00  pm   South  Dakota  Council  Mee?ngSeptember  12     6:00  -­‐  8:00  pm   Governors’  Recep?on *Council  Mee?ng  and  Governor’s  Recep?on  held  at Tom  Braithwaite’s  home  -­‐-­‐-­‐  3705  S.  Lewis  Ave.,  Sioux  Falls,  SD    57103Thursday,         7:00  am     Registra.on  BeginsSeptember  13     7:25  am     Welcome  &  Introduc.ons                 -­‐Thomas  M.  Braithwaite,  Governor         7:30  am     Morning  Session  Begins  -­‐  Mark  Lounsbery,  Moderator         7:30  am     SEP  Module:    Hospice  &  Care,  Part  I                 -­‐LuAnn  Eidsness         9:00  am     Update  on  Clostridium  Difficile  Infec.on  -­‐  Jorge  Gilbert         10:00  am     BREAK         10:30  am     Recogni.on  &  Management  of  Moderate  to  Severe                   Persistent  Ashtma  -­‐  Michael         11:10  am     College  Update  with  Q&A  -­‐  Thomas  G.  Tape,  ACP  Regent         12:00  pm     LUNCH  PROVIDED               Town  Hall  &  Business  -­‐  Tom  Braithwaite         Washington Pavillion of Arts and Science
  3. 3. Falls ParkThursday,       1:00  pm     AXernoon  Session  Begins  -­‐AnneYe  Bosworth,  ModeratorSeptember  13     1:00  pm     Have  I  Got  A  Case  For  You!:    A  Cau.onary  Tale                   -­‐  Hesham  Elgouhari         1:20  pm     Understanding  Medical  Controversies:    When  Evidence  and                   Theory  Collide  -­‐  Tom  Tape         2:20  pm     Have  I  Got  A  Case  For  You!:    Incidental  (or  Accidental)                   Finding  in  the  Immunosupressed  Popula.on  -­‐  Nathan  Miller         2:40  pm     BREAK         3:10  pm     Management  of  HIV  -­‐  Donna  Sweet         4:10  pm     HIV/AIDS:    Common  Infec.ous  Complica.ons  -­‐  Jennifer  Hsu         4:55  pm     Mee?ng  Adjourned                       6:30  pm     Awards  Banquet                       Minnehaha  Country  Club                     3101  W.  22nd  St.
  4. 4. Friday,  September  14  7:00  am     Advancement  to  Fellowship  Con?nental  Breakfast**7:30  am     Morning  Session  Begins    -­‐  MaY  Jahraus,  Moderator7:30  am     Hypertension  in  Two  Different  Worlds           -­‐  Lankhort  8:30  am     What’s  New  for  Women’s  Health:    The  Good,  The  Bad,         The  Indifferent  -­‐  Donna  Sweet9:30  am     Have  I  Got  A  Case  For  You!:    Stones,  Bones,   St. Joseph’s Cathedral         Abdominal  Groans,  Psychiatric  Moans  &           Diagnos.c  Unknowns  -­‐  Rick  Holm9:50  am     BREAK  10:20  am     Donald  Humphrey’s  Scholars’  Day  Winner:         Coronary  to  Pulmonary  Artery  Fistulas  During         Bacterial  Endocardi.s    A  Rare         Incidental  Finding  -­‐  John  Kelly  Wachira10:40  am     Resident  Poster  Session         Pooja  Aggarwal,  Vanessa  Garcia-­‐Chen,   Old Courthouse Museum         Mariko  Saso-­‐Hagiwara,  Dilpriya  Mangat,         Pavithra  PaYabiraman,  Troy  Rowekamp  and                   Then  Tong      11:10  am     Have  I  Got  A  Case  For  You!:  Bringing  Down  Rocky         -­‐  Jeremy  Cauwels11:30  am     LUNCH  PROVIDED       Can’t  Anyone  Here  Play  This  Game?:  Broken  Poli9cs, Pettigrew Museum         Broken  Health  Care,  Broken  Promises  -­‐  Bob  Doherty     **Any  member  contempla?ng  applying  for  advancement  to  Fellowship  should  a_end,  as  well  as  current  Fellows   who  can  assist  those  seeking  Fellowship  by  ac?ng  as  seconders  to  their  applica?on.
  5. 5. Friday,  September  14  1:30  pm     AXernoon  Session  Begins  -­‐  Marc  Aldrich,  Moderator1:30  pm     Inpa.ent  and  Outpa.ent  Diabetes  Management:    An  Endocrinologist’s   -­‐  Brandon  Allard    2:20  pm     BREAK2:50  pm     SEP  Module:    Hospice  &  Care,  Part  II  -­‐  Joann  BenneY4:20  pm     MEETING  ADJOURNEDMODERATORS: Marc  N.   Aldrich,   MD,   ACP   Member,   received  his  undergraduate   degree  at  Augustana  College   (Sioux   Falls)   and  his  medical  training   at   Sanford   USD   School  of   Medicine.     Following  medical   internship   with   the   Naval   Medical   Center   in   San   Diego   he   completed   Internal   Medicine   residency  at  the  University  of  Iowa  Hospitals  and  Clinics.    He  prac.ced  general  Internal  Medicine   with   Sanford   Health   from   1992   00   2004,   and   has  been   serving   Rapid   City   Regional  Health   System  as  a  hospitalist  since  2004.    He  and  his  wife,  Cynthia,  have  three  children. Anne_e   Bosworth,   MD,   ACP   Member,   is   an   informa.cs  internal   medicine   physician   filled   with   the   passion  to  change   the  world  -­‐   one  life   at   a  .me.     She  is  the  founder  of   Independent  Medicine  Prof.  LLC,   and  Health  Strategies,  a  non-­‐profit  organiza.on   focused   on  accessible,  quality  health  care  for   marginalized  popula.ons  in  Sioux  Falls,  SD.       Dr.  Bosworth  is  cer.fied  to  provide  not  only  general  prac.ce   services  but  also  a  recognized  expert  in  nutri.on,  exercise  and  mental  condi.oning  programs.     She  is  also   the   founder   of   ECHO   Kids   a  local   that   is   aimed   at   reducing   childhood   obesity   and   lowering   childhood  rates  of   diabetes.      Dr.  Bosworth  is  involved  in  helping  reform  healthcare  around  the  globe.  She   was   recently   in   Hai.,   heading   several   medical   mission   trips   providing   necessary   services   to   rural   and   urban  areas.    Dr.  Bosworth  is  blessed  to  share  her  life  with  her  husband,  Chad,  and  their  three  children. Ma_hew  D.  Jahraus,   MD,   ACP   Member,  has  been  in  prac.ce  at  Sanford  USD  Medical  Center   for   2   years  with   the   Sanford   Clinic   Hospitalist   group.   He  is  an  Assistant   Clinical  Professor   at   the   Sanford   School   of   Medicine  at   the  University   of   South   Dakota.   He   is  in   both  medical   student  and  resident  educa.on  on  the  hospitalist   teaching   service.   His  areas  of  interest  include   peri-­‐  medicine  and   pa.ent   educa.on.    Dr.   Jahraus  received   his  medical  degree  from   Midwestern   University-­‐Chicago   College   of   Osteopathic   Medicine   and   completed   his   Internal   Medicine   residency   at   the   University  of  Nebraska  Medical  Center.  He  currently  resides  in  Sioux   Falls  with  his  wife  Allison  and  two  sons.   Mark  G.  Lounsbery,  DO,  ACP   Member,   is  a  2005  graduate  of  Des  Moines  University  and  a   of  Beresford,   South   Dakota.  He  is  currently   an  Internal  Medicine  Physician  at   The  Sanford  Adult   Medicine   Clinic.  Dr.   Lounsbery   has  been  a  member  of  the  American  College   of  Physicians  since   2008.  He  also  is  a  member  of  the  South  Dakota  State  Medical  Associa.on,  as  well  as,   serving  as   Clinical  Faculty  at  The  Sanford  School  of   Medicine  of  The  University  of  South  Dakota  since  2005.   In  his  free  .me  he  enjoys  spending  .me  with  his  family   and  genng  in  a  round  or   two  of  golf   when  possible.
  6. 6. FACULTY: Brandon   L.   Allard,   MD,   has  been  in   prac.ce  at   Sanford  USD  Medical  Center   for   8   years  as  a   clinical  endocrinologist.  He  is  an  Assistant   Clinical  Professor  at  the  Sanford  School  of  Medicine  at   the  University   of  South  Dakota.    Dr.   Allard  received   his  medical   degree  from  the  University   of   Minnesota  Medical  School,  completed  Internal  Medicine  residency  at  AbboY  Northwestern,  and   completed  a  3  year   Endocrine  Fellowship  at  the  Mayo  Clinic.  He  lives  in  Sioux  Falls  with  his  wife   and  two  children.   Joann   Benne_,   MD   is   a   Board   Cer.fied   Internal   Medicine   Physician   with   Subspecialty   in   Pulmonary   Medicine   and   Hospice   &   Medicine.     In   addi.on,   she   has   had   the   opportunity  to  work  in  the  Avera  eICU   as  a  virtual  Intensivist.    Dr.  BenneY  has  prac.ced  in  the   Sioux   Falls  area  for   11   years.     She  is  an   Associate  Professor   of  Medicine  at  Sanford  School  of   Medicine.    Her  enthusiasm  for  educa.on  and  holis.c  medical  prac.ce  are  apparent  in  her  work  . Thomas   M.   Braithwaite,   MD,   FACP   is   the   current   Governor   of   the   South   Dakota   ACP.     He   graduated   Augustana  College   in   1978   and   Sanford   USD   School  of   Medicine   in   1982.     From   1982-­‐85  he  did  his  Internal  Medicine  residency  at   University  of  Iowa  Hospitals  and  Clinics  in  Iowa   City,   IA.    Dr.   Braithwaite  then  prac.ced  general  Internal  Medicine  from  1985   to  2003  at  Sanford   Health  in  Sioux  Falls,  SD.    He  stayed  at  Sanford  Health  as  a  Hospitalist   from  2003  to  2010  and  is   now  Chief   Quality   Officer.     Along  with   his  wife   Tacey,   they   have   two   children.     His  interests   include  music,  running,  and  reading. Jeremy  M.  Cauwels,  MD,  FACP  was  born  in  Viborg,  SD  in  1976.    He  grew  up  in  Hawarden,  IA,  and   aYended  the  University  of  Northern  Iowa.     Medical  School  was  at   the  University  of  Iowa  College   of  Medicine,  and  Residency   was  at  the  University   of  Kansas  where   he   was  selected   to  be  Chief   Resident.     He  returned  to  Sioux   Falls  6   years  ago,   and  has  been  a  Hospitalist   at   Sanford  USD   Medical  Center  since. Bob   Doherty  is  Senior   Vice  President  of  Governmental  Affairs  and   Public  Policy  for  the  American   College  of   Physicians  (ACP),   the  largest   physician  specialty   society   and   second  largest   medical   organiza.on   in   the   U.S.   ACP   represents   130,000   internal   medicine   physicians   and   medical   students.     Mr.   Doherty   has  over   31   years  of   health   policy   experience  and  is  an   accomplished   presenter   at   health   conferences.     From   1979   to   1998,   he  worked   in   the   governmental  affairs   department  of  the  American  Society   of  Internal  Medicine,  and  with  the  merger  of  ASIM   and  ACP   in  June,  1998,  joined  the  ACP  as  Senior  Vice  President  for  Governmental  Affairs  and  Public  Policy.     LuAnn   M.   Eidsness,   MD,   FACP   aYended   medical   school  and   completed   her   Internal  Medicine   Residency   at   Sanford   School  of   Medicine.   She   joined   SSOM   in   1990   and   is  now   Chair   of   the   Department.   She   teaches   biomedical   ethics   and   hospice/   medicine   (HPM)   to   the   students  and  residents.   She  is  board   cer.fied   in   both   internal  medicine  and   hospice/   medicine.  She  is  the  medical  director  of  Ethics  and  HPM  at  Sanford  Health  in  Sioux  Falls.
  7. 7. FACULTY: Hesham  M.   Elgouhari,  MD,  FACP  is  the  medical  director  of  the  Avera  Medical  Group  Liver  Disease   center   in   Sioux   Falls,   SD.     Dr.   Elgouhari   completed   his   fellowship   in   Hepatology/Transplant   Hepatology  at  the  Cleveland  Clinic  in  Cleveland,   OH.    He  has  also  completed  an  Infec.ous  Disease   fellowship  at  the  University  of  New  Mexico  in  Albuquerque,  NM.     Dr.  Elgouhari  is  board  cer.fied  in   Internal  Medicine  and  Infec.ous  Disease.    His  special  interests  include  Transplant  Hepatology,  viral   hepa..s,  autoimmune  and  metabolic  liver  disease. Jorge   A.   Gilbert,  MD  has  been  in  clinical  prac.ce  at   Sanford  Health  for   12   years.  He   is  an   member  of  the  medical  staff  at  Sanford  USD  Medical  Center,  and  is  an  Associate  Clinical  Professor   at   the  Sanford  School  of   Medicine  at  the  University   of  South  Dakota.   Always  the  teacher,   he  is   highly   regarded  as   a  technically   superior   endoscopist,   and   is  a   favorite  amongst   students  and   residents  alike.   He  is  widely   respected  for   his  knowledge  of  the  care  and  treatment   of  the  full   range   of   GI  problems  including   hepatology   and­‐biliary   concerns  along   with  a  large   endoscopy   prac.ce.   Dr.   Gilbert   received   his   medical   training   at   pres.gious   academic   medical   centers  including  Harvard,   MassachuseYs  General  Hospital,   and   the   Mayo   School  of  Medicine.   A  of  Ecuador,  he  resides  in  Sioux  Falls  with  his  wife  and  two  daughters.” Richard   P.   Holm,   MD,   FACP   is   an   outpa.ent   and   hospital   internist   prac.cing   30+   years   in   Brookings.  His  interests  in  medicine  include  the  general  broad  sweep  of  diagnos.c  and  therapeu.c   problems   adults   and   elderly   encounter   living   on   the   prairie.   He   performs   colonoscopy,   echocardiography,  and  an.cipates  developing  some  in  teaching  hand  held  ultrasound  for   the  generalist.    For   the   past  10   years,   Dr.   Holm  has  been  medical  director   of  the  PBS   television   program   OnCall.     In   2011,   he  and   his  wife  Joanie   founded   Healing   Words  Founda.on,   whose   mission   is   to   enhance   health   and   diminish   suffering   through   the   communica.on   of   useful   informa.on,  based  on  honest  science,  provided  in  a  respecqul  and  compassionate  manner. Jennifer   L.   Hsu,   MD,   ACP   Member,   aYended   medical  school  at   the  University   of   Missouri  and   completed  residency   and  fellowship  training  in  Infec.ous  Disease  at  the  University   of  Wisconsin.   AXer   fellowship,   she   was   on   the   University   of   Wisconsin   faculty   before   taking   a   posi.on   at   Sanford  Health.  Dr.  Hsu  is  in  stewardship  and  infec.on  control  within  the  Sanford   Health   system   and   also   par.cipates  ac.vely   in   medical   educa.on   ini.a.ves   at   Sanford   USD   School  of  Medicine.  In  her  free  .me,  she  enjoys  hiking,  traveling,  and  cooking. Chris?na   E.   Lankhorst,   MD,   ACP   Member   grew   up   in   Sioux   Falls,   SD   and   aYended   Medical   School   at   Case   Western   Reserve  University.     She   completed   her   residency   and  fellowship   at   University   Hospitals  Case  Medical  Center.    Dr.  Lankhorst  is  board  cer.fied   in  Internal  Medicine,   Nephrology,  and  most  recently   became  a  Cer.fied  Hypertension  Specialist.     She  joined  Sanford   Nephrology   Clinic  in  August   2010   and  is  ac.vely   involved  with  the  Na.onal  Kidney   Founda.on   and  now   the  American  College  of  Physicians.     Outside  of  work  Dr.   Lankhorst   enjoys  spending   .me   with  her   family.     Recently,   she  and  her   husband  Trent   welcomed  a  new   addi.on  to  their   Nate   J.   Miller,   MD,   ACP   Member,   aYended  medical  school  and  did  his  residency   at   Sanford   School  of  Medicine   at  the  University   of   South  Dakota.     Dr.  Miller  was  chief  resident  un.l  June   2012   and   is  currently   a  hospitalist   at   Avera  McKennan   and   is  ac.vely   involved  in   the  Young   Physicians  Council  for   the  SD   ACP.     His  areas  of   interest   are  medical  educa.on   and   quality   improvement  and  he  is  also  a  member  of  the  Society  of  Hospital  Medicine.
  8. 8. FACULTY: Michael  P.  Pie?la,   MD,   ACP   Member,   is  board  cer.fied  in  Internal,  Care  and   Pulmonary   Medicine  and  a  Fellow  of   the  American  College  of  Chest  Physicians.     He  is  an  Academic  Professor   of  Internal  Medicine  at  the  University  of  South  Dakota,  and  the  Chief  of  Staff  and  Medical  Director   of  the  ICU  at   Avera  Sacred   Heart   Hospital  in  Yankton,  SD.     He   is  also  a  member  of  the  board  of   directors  at   Sacred  Heart.     Dr.,   a  South   Dakota,   aYended   medical   school  at   the   University   of   South  Dakota  and  completed  his  internship,  residency   and  fellowship  training  at  the   Mayo  Clinic   in  Rochester,  MN.    He  has  been  prac.cing  medicine  at  the  Yankton  Medical  Clinic,   P.C.   since  2006. Donna  E.  Sweet,  MD,  MACP,  is  a  Professor  of  Internal  Medicine  at  the  University  of  Kansas  School   of   Medicine-­‐Wichita,   KS.     She   is  a   Master   in   the   American   College   of   Physicians   and   is  the   Immediate   Past   Chair   of   the  American  College  of   Physicians   Founda.on   Board  as  well  as  Chair   Emeritus  of   the   American  College   of   Physicians  Board   of   Regents.     Dr.   Sweet   is  also  an  AMA   delegate  for   the  ACP   and  is  a  member   of   the  Council   on  Medical  Service  of   the  AMA.     She  is   cer.fied  as  an  HIV  specialist  by  the  American   Academy  of  HIV  Medicine  and  na.onal  Co-­‐Chair   of   the  CDC  HRSA  AIDS  Advisory  Council  (CHAC).    She  is  also  the  Principal  Inves.gator  and  Director  of   the  Kansas  AIDS  Educa.on  and  Training  Center.   Thomas   G.   Tape,   MD,   FACP,   is  the  current   Chair   of   the  Board  of   Governors  of   the  American   College  of   Physicians  (ACP).     Dr.   Tape  has  been  a  Fellow  of   the  American  College   of  Physicians   (FACP)  since  1991.   He  has  also  recently  served  as  ACP  Governor  for  the  Nebraska  Chapter.     Board   cer.fied  in  internal  medicine,  Dr.   Tape  earned  a  bachelor’s  degree  from  Dartmouth  College  and  a   medical  degree   from   Washington   University   School  of  Medicine  in  St.   Louis.   He  completed   an   internal  medicine  residency  and  fellowship  at  the  University  of  Rochester  in  New  York.     Dr.  Tape  is   a  professor   of   internal   medicine  at   the  University   of   Nebraska   College  of   Medicine,   where  he   serves  as  chief   of   the  division  of  general   internal  medicine.     He  is  also  the  vice-­‐chair  of  clinical   affairs  of  the  department  of  internal  medicine. PLANNING COMMITTEE: Thomas  Braithwaite,  MD,  FACP                                            Jeremy  Cauwels,  MD,  FACP                                                Eric  Larson,  MD,  FACP "e reward for work well done $ % o&ounity to do mor( --Jonas Salk, MD
  9. 9. Residents Presenting Posters: Pooja Aggarwal, MD, Associate Vanessa Garcia-Chen, MD, Associate Mariko Saso-Hagiwara, MD, Associate Dilpriya Mangat, MD, Associate Pavithra Pattabiraman, MD, Associate Troy Rowekamp, MD, Associate Then Tong, MD, AssociateDonald Humphrey’s Scholars’ Day Winner: John Kelly Wachira John Kelly Wachira, MD, Associate Queen Bee Mill - Sioux Falls, SD Downtown Trolley
  10. 10. CME ACCREDITATION:The American College of Physicians is accredited by the Accreditation Council for Continuing MedicalEducation (ACCME) to provide continuing medical education for physicians.The American College of Physicians designates this live activity for a maximum of ____ AMA PRA Category 1Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in theactivity.HOTEL:Best  Western  Ramkota,  3200  W.  Maple  St.,  Sioux  Falls,  SD.Guests   must   call  the  Ramkota   to   make   individual  reserva.ons  at:   605-­‐336-­‐0650.   PLEASE   CALL   THE   HOTEL  DIRECTLY;   SPECIAL   GROUP   RATES  AND   ROOM   BLOCK  ARE   NOT   AVAILABLE   THROUGH   THE   BEST   WESTERN  ONLINE   RESERVATIONS   SYSTEM.   AYendees  must   iden.fy   themselves  as  being   part   of   American   College   of  Physicians  Conference  to  ensure  the  special  rate.    Hotel  room  rates  start  at  $90/night.    All  reserva?ons  must  be  received  by  8/13/02.ExtensionsTo  accommodate  early  arrivals  and  late  departures,  group  guest   room  rates  will  be  extended  three  days  prior  and  three  days  beyond  your  scheduled  conference  date,  based  on  availability.  HOW TO REGISTER:• If   you   need   more   informa.on   on   the,   please   contact   Kris   Rahm   at   605-­‐339-­‐9804   or• Registra?on  can  be  completed  by  one  of  the  following: -­‐Faxing  the  completed  registra?on  form  to  605-­‐271-­‐9227  (no  cover  sheet  necessary) -­‐Mailing  the  completed  registra?on  form  to:     South  Dakota  ACP,  4904  S.  Sweetbriar  Dr.,  Sioux  Falls,  SD    57108• For  informa.on  on  College-­‐related  issues,  contact  the  South  Dakota  Chapter  Governor:     Thomas  M.  Braithwaite,  MD,  FACP   (605)  333-­‐6564• Take  advantage  of  Early  Bird  fees  prior  to  August  15th.     Pre-­‐registra?ons  must  be  received  by  September   5th.     Aher   that   date,   you   must   register   on-­‐site   and   there   is   an   addi?onal   $50   fee   —save   money   by   registering  now.  • To  access  our  online  informa.on  or  to  print  another  registra.on  form  for  a  friend  or  colleague,  go   to
  11. 11. Pre-­‐registra?ons  must  be  received  by  September  5th.    Aher  that  date,  you  must  register  on-­‐site  and  there  is  an  addi?onal  $50  fee   —save  money  by  registering  now.   South Dakota ACP 2012 Registration Form* • Registration can be completed by one of the following:Please -Faxing the form to 605-271-9227 (no cover sheet necessary) -Mailing the form to: South Dakota ACP, 4904 S. Sweetbriar Dr., Sioux Falls, SD 57108complete Attendee’s Name: ___________________________________________ (MD) (DO)each Credit Card Billing Address:______________________________________________ ____________________________________________________________________blank Phone:________________________ E-mail for receipt:_______________________space; Registration Fees (PLEASE NOTE EARLY BIRD REGISTRATION): Category – Please check one: Before 8/15/12 After 8/15/12 Amount to beeven Charged ACP Member $300 $400 $ Non-Member $450 $550 $with ACP Resident/Student $0 $50 $a zero Guest Fee for Governor’s Reception and Awards Banquet Guest Name: $75 $100 $or I wish to make a voluntary $ donation to support theN/A South Dakota ACP TOTAL AMOUNT DUE $ -- PLEASE INDICATE WHICH MEAL(S) YOU AND/OR GUEST WILL BE ATTENDING Thank EXAMPLE MEAL%OR%EVENT ATTENDEE X GUEST X Wednesday,%September%12%–%Governor’s%Reception You! %%%%%%FHeld%at%Tom%Braithwaite’s%Home %%%%%%%%%%%%%%%%%%%%%%%%3705%S.%Lewis%Ct. %%%%%%%%%%%%%%%%%%%%%%%%Sioux%Falls,%SD%%%%%%%% -- Thursday,%September%13%F%Lunch N/A Thursday,%September%13%–%Awards%Banquet Friday,%September%14%F%Fellowship%Breakfast N/A*Registrations Friday,%September%14%F%Lunch N/A cannot be CHARGE TO: _________________________________________________________ processed (Name as it appears on card) without _____VISA _____MC _____AMERICAN EXPRESS _____DISCOVER complete information. CARD #_______________________________________________________________ EXP. DATE: ______________________ SECURITY CODE: ____________________ (3 digits on back or 4 digits on front of card) SIGNATURE:___________________________________________________________