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             Home > www.duerinckx.com                                                                     Updated Nov 04, 2007

64 slice Coronary CT Angiography
VISITING FELLOWSHIPS  or Read-with-Expert Sessions
with Dr Duerinckx
.... we have another form for Cardiac CT & MR Courses

 

Wondering about DATES? ...always just before or after a CT course,
or on Mon-Wed-Fri almost every week.. just call us first..

 STEP #1: CALL US to discuss and SELECT DATES for LEVEL I, II or III Training
Our NEW PHONE: 216-778 4020 in day time
Call cell 216-466 4141 on week-ends & evenings

STEP #2:  Complete this form, PRINT it and then FAX it to us (and mail your check) to:
       Dr Duerinckx, Attn: Cardiac Education Coordinator,
Department of Radiology
MetroHealth Medical Center
2500 MetroHealth Drive
Cleveland, Ohio  44109-1998

   Call Dr Duerinckx's Office
Metro Cardiac Education Coordinator's office
Cindy Frederick at : +1-216-778 4034   (new)
or e-mail RadiologyCourses@MetroHealth.org
Our FAX: +1-216-778 4046
Back-up FAX: 216-778 8593
 

Look for HOTEL and AIRPORT Info at the bottom of this form

Pre-REGISTRATION FORM for Cardiac CT
Visiting FELLOWSHIPS in 2007-2008

First Name
Last Name Degree(s)
Institution
Street Address/Suite
City
State/Province     Postal Code 
Country
Office Phone

Cell Phone

Office
Cell Phone (GSM Phone)
Country Code        City               Phone Number

Name of Your Secretary NAME of person to contact with problems
e-mail of Your Secretary

Fax
 

E-mail

Indicate if you Pay by CHECK or CREDIT CARD
                           Amount Paid in US $

Signature         To Approve Credit card Payment
(Ignore this signature line if you are e-mailing us this form as a .pdf file)

Name (printed) NAME as Printed on Your Credit Card
 BILLING ADDRESS for Credit card   

Type of CREDIT CARD        CREDIT Card Payments
We only accept VISA, Mastercard and DISCOVER Card.
      We can not accept American Express or other cards. Sorry.
CARD NUMBER                  
                                                                                         e-mail this form to us as a .pdf file
Expiration date                   or
AMOUNT                             FAX this form to us


 Send to us via Secure FAX to: ++1-216-778 4046 (FAX)
In case of problems, use Back-up FAX: 216-921 8345 !!!!
 Please make checks out in US Dollars Only. Make checks payable to :
           "MetroHealth, Radiology Education Account"

**** PLEASE MAKE SURE TO READ DISCLAIMER FIRST (Click here or See below) ****

Please MARK your Preferred Date(s) for Visiting Fellowship
or Reading-with-Expert Sessions:

(1) Jan 2008 in OH


(2) Feb 2008 in OH

(3) Call for any other period

Since Feb 2007 this training is offered in Cleveland, OH

Please FAX us this completed form BEFORE
calling the Dr Duerinckx's office
to pick a date;
Send money only after a
date has been picked


Only send check after we agree on dates:
Make checks payable to :
"MetroHealth, Radiology
Education Account"

Please go to Greystone Imaging Center (GIC) for these educational activities.

A late fee of $100 applies if we do not receive your check at least 4 weeks prior to the educational event (Fellowship Visit or read-with-expert session)

 

       US $ ________
Options:
$1,200 /day to observe CT scanning and practice (full participation) after 1 PM;

Special AM sessions (9 AM to noon):
$1,200/day to review cases on Teaching Files with supervised 3D workstation reviews
(by special appointment only;
for groups of 3 people or more)


Please read Disclaimer below, and print and sign your name:

PRINT Your Name:
_____________________________
(Print clearly in this space)

SIGN Your Name:
_____________________________
(Acknowledge Disclaimer below)

DISCLAIMERS:
By signing above, you acknowledge that you have read these disclainers.
Please go to Greystone Imaging Center (GIC) for these educational activities.

1)  CANCELLATION POLICY: Full refunds, less $75 administration fee, will be given provided a written (or FAX or e-mail) notice of cancellation is received at least 4 weeks prior to the teaching event. Within the four weeks prior to an event no refunds will be issued; however, you are allowed to designate another person to attend up to 1 week prior to the event (for an adminstrative fee of $75).

2) LATE FEES: A late fee of $100 will be assessed if you register less than 4 weeks in advance; any such late registration is non-refundable.

Disclaimer #1: If your Visiting Fellowship time period is cancelled or post-poned (by us) you can either get a REFUND, or be automatically re-registered for another period. If you purchased advance air travel and hotel accomodations, you will be responsible for any added travel-related costs in case of cancellation or postponemen to the next period.


Disclaimer #2 for afternoon OBSERVATIONAL VISITING FELLOWSHIPS: As we do not fully control patient flow and when patients schedule their Cardiac CT examinations, we can not guarantee how many patients will have a test during your short Visiting fellowship. We are still in the process of optimizing patient flow. For one-day visitors we will review older CT examinations if no new examinations are scheduled. Most of our Cardiac CT scanning takes place between 2 PM and 5 PM, but there is an extensive patient preparation process starting around 11 AM. Post-processing and analysis of Cardiac CT studies is done after 5 PM and can continue the next morning (next morning session not included in 1-day visits). No syllabus provided. These visits start at 1 PM. There are no activities planned in the morning. There is always the options of also booking a Read-with-Expert session in the morning, but only on selected days.


Disclaimer #3 for READ-with-EXPERT Sessions: these are 3 hour READING SESSIONS: We plan 3 hour reading sessions from 9 AM to noon time, and can never predict if we will have network or computer crashes. The start of reading sessions may change depending upon urgent patient care issues. Please call ahead to reserve a spot. If more than 3 people wish to attend, the price increases by $1,000 per person. No syllabus provided. This is NOT a CME activity.

PRINTING: When printing this form, please reduce to 70% (only possible when printing from an Apple/Mac computer) to fit on one page.

Suggested Hotel(s) in Cleveland, OH:
Spending a week-end in Cleveland, OH?
TOURISM Info can be downloaded here....click here

***Hotel Information.. download here***.
Directions to Metro.....here
Info on Cleveland....here

 

Airports: Cleveland, OH  can be reached by flying into Cleveland  Hopkins  International. Airport (http://www.clevelandairport.com/; Symbol: CLE).