Download 2017 Meeting Registration - Texas Society of Oral and Maxillofacial

2017 Combined Annual Meeting
April 20-23, 2017
Hyatt Regency Scottsdale Resort & Spa
at Gainey Ranch
Scottsdale, Arizona
WELCOME!
It is time to make your reservations for the 2017 Combined Annual Meeting of the
Southwest Society of Oral and Maxillofacial Surgeons, the Texas Society of Oral and
Maxillofacial Surgeons, the Midwestern Chapter of Oral and Maxillofacial Surgeons and the
Oklahoma Society of Oral and Maxillofacial Surgeons, in joint providership with the
American Association of Oral and Maxillofacial Surgeons. We are excited about the
opportunities to be presented at this year’s meeting at The Hyatt Regency Resort & Spa at
Gainey Ranch in Scottsdale, Arizona April 20-23, 2017.
Over the past 88 years, the Southwest Society of OMS has provided excellent annual
meeting opportunities and this year is no exception. The meeting will kick off Thursday
morning with state and regional board of directors meetings followed by our annual golf
tournament to be held at the beautiful Gainey Ranch Golf Club. On Friday, the renowned Byrd-Tilson-Walker
Resident’s Day Program will provide an opportunity for us to recognize the best and brightest from training programs in
the Southwest and Midwestern region. This is the 6th opportunity for our society to present the Robert V. Walker, DDS
award to a resident for the most outstanding presentation during the program. Friday afternoon, attendees will then
enjoy the University of Oklahoma sponsored “Reichmann Lecture” where Dr. Stuart Lieblich will present current
concepts and treatment modalities for the delivery of Office Based Anesthesia. On Saturday, our Keynote Speaker Dr.
Michael Block will present a two- part lecture addressing maxillary full arch restoration utilizing state of the art
technology followed by a discussion on the management of dental implant complications which we see in our everyday
practice. We are again pleased to partner with AAOMS to provide up to 16 hours of continuing dental (ADA CERP) and
medical (ACCME) education credits for our participants.
One of the best parts of the SWSOMS meeting is the opportunity to have great social events where we interact with
our friends and colleagues from the southwest region. Make sure to attend our receptions in beautiful outdoor venues
on both Thursday and Friday evenings. After Friday’s reception, Alumni from Baylor (BOMSAA), The University of Texas
Health Science Center San Antonio (UTHSC-SA) and Oklahoma University combined with the Oklahoma Society of
OMS’s have arranged for special dinners in one of the acclaimed dining areas. We also have an exciting companion
event lined up at the Desert Botanical Gardens on Friday morning. Join my wife, Mary Beth, on an amazing hike with
an expert in desert plants and native cultures through a dramatic desert landscape and flora. The event will conclude
with a gourmet lunch at Gertrude’s outdoor patio right next to the gardens. Don’t forget to get your tickets for our
Presidents Event on Saturday evening with dinner, live music and dancing in a beautiful patio setting.
The Hyatt Gainey Ranch is a great property for a meeting of our size with awesome amenities and an ideal location.
This is an excellent meeting to bring your spouse and family to with its access to an amazing pool complex, golf, tennis
and a world class spa facility. There are innumerable desert experiences which can be arranged through the hotel with
an average daytime high temperature of 85 degrees for the month of April. I am sure you will enjoy all that the Hyatt
Gainey Ranch has to offer.
I hope you will make plans to join us in beautiful Scottsdale for what will be an excellent meeting in a beautiful resort.
Make your flight and hotel reservations soon and I look forward to seeing you in the desert this April.
~Scott W. Searcey, DDS, President
Friday, April 21, 2017
Byrd-Tilson-Walker Residents’ Day Program
FEATURED
SESSIONS
CDE/CME Credits: 4 hours
Outstanding young doctors from the southwest region will present topical basic science and clinical research initiatives
ongoing at their respective institutions of study.
OBJECTIVES:
• To provide a broad overview of the extensive clinical scope of oral and maxillofacial residency training
Programs.
• Provide those in private practice with the additional knowledge regarding current advances in treatment
modalities and the application of technology and new treatment techniques available.
• To encourage future surgeons to remain involved in clinical research in an effort to uphold quality and expertise
of the specialty.
Anesthesia Focus: “Ambulatory Anesthesia: Care Based Focused Review
of Techniques and Complications”
Stuart E. Lieblich, DMD
CDE/CME Credits: 4 hours
The provision of ambulatory anesthesia is a vital component to the practice of oral and maxillofacial surgery. A
contemporary review of anesthesia as practiced by the oral surgeon including a discussion of patient evaluation,
medications and determining who can be treated in an office setting will be discussed. Actual case scenarios will be
reviewed to illustrate various issues throughout the day. Included in the discussions will be some recommendations on
local anesthetic use and integrating oral sedation into an oral surgery practice.
OBJECTIVES:
• Understand basic medical aspects of common systemic diseases, including cardiovascular disease, diabetes,
neurologic, and immunologic diseases and how they impact on our anesthesia options.
• Review common and some uncommon medical and anesthetic emergencies that may occur in the office.
• Provide oral sedation techniques specific for the oral surgery practice.
• Review management protocols of common medical emergencies that may occur in the office via actual casebased scenarios.
The University of Oklahoma
Department of Oral & Maxillofacial Surgery
SPONSORED BY:
The Reichmann Lecture
Saturday, April 22, 2017
FEATURED
SESSIONS
KEYNOTE LECTURE:
Michael S. Block, DMD
CDE/CME Credits: 4 hours
Lecture 1: Practical Solutions for the Maxillary Full Arch Restoration –
Treatment Planning, Choice of Final Prosthesis, Surgical Methods Using
Technology
This presentation will demonstrate practical algorithms for full arch maxillary prosthetic rehabilitation including when
to remove bone, when to avoid flanges, methods to plan and use navigation, and placement of the flangeless
prosthesis for long term maintenance. Communication with the restorative dentist and lab will be discussed because
of multiple levels of experience with this restorative method.
OBJECTIVES:
• Be able to identify patients who are excellent candidates for esthetic flangeless full arch restorations.
• Understand the need for preoperative imaging to accurately place implants.
• Be able to guide their restorative and lab colleagues in the management of the treatment planning, surgical,
and restorative portions of the patient’s treatment.
Lecture 2: Treatment of Cases Referred To You With Dental and
Implant Problems – Sequence of Treatment Planning, Grafting, and
Prosthetic Options for Single Teeth to Multiple Esthetic Teeth
This presentation will discuss how to treat the patient referred to you with significant dental or implant related
complications that include loss of hard and soft tissue. Multiple anterior maxillary cases will be presented with results
that can be considered ideal and those that are compromised because of the previously lost tissue.
OBJECTIVES:
• Be able to utilize pre-operative examination to form a final restorative plan.
• Understand the need for staged approach to re-establish soft tissue thickness in the esthetic zone.
• Be able to identify realistic expectations in the patient who has suffered loss of hard and soft tissue in the
esthetic zone.
Saturday, April 22, 2017
FEATURED
SESSIONS
OMSNIC Risk Management for the Oral and Maxillofacial Surgeon
Colin S. Bell, DDS, MSD
CDE/CME Credits: 4 hours
In a collaborative learning environment, OMSNIC’s team of tandem speakers integrates case examples with non-clinical
issues commonly seen in oral surgery claims. The four hour lecture highlights risk management techniques that can
improve patient care and lessen the risk of claims. Case examples involving anesthesia complications, failure to
diagnose, wrong tooth extraction, implants and medication related issues will be discussed.
•
•
•
•
•
•
OBJECTIVES:
Implement and practice appropriate anesthesia management systems to achieve quality safety based patient
care.
Identify common problems in implant placement to improve patient care and prevent or reduce untoward
events.
Recognize the issues that can lead to wrong tooth extraction with a focus on reducing frequency.
Implement strategies to help prevent delayed diagnosis or failure to diagnose cases.
Understand how documentation issues can impact patient care.
Understand the relationship between medications, drugs, and allergic reactions to minimize the potential risks in
the oral and maxillofacial surgery practice.
CDE/CME
CREDIT
16 hours CDE/CME CREDIT
Through Joint Providership with AAOMS
This continuing education activity has been planned and implemented in accordance with the standards of
the ADA Continuing Education Recognition Program (ADA CERP) through the joint efforts between the
American Association of Oral and Maxillofacial Surgeons and the Southwest Society of Oral and
Maxillofacial Surgeons, Texas Society of Oral and Maxillofacial Surgeons, Midwestern Chapter of Oral and
Maxillofacial Surgeons and the Oklahoma Society of Oral and Maxillofacial Surgeons.
American Association of Oral and Maxillofacial Surgeons is an ADA CERP Recognized Provider. ADA CERP is
a service of the American Dental Association to assist dental professionals in identifying quality providers of
continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor
does it imply acceptance of credit hours by boards of dentistry.
American Association of Oral and Maxillofacial Surgeons designates this activity for 16 continuing education
credits.
AGD- Accepted Program Provider
FAGD/MAGD
5/1/14-6/30/18
Provider ID# 214680
This activity has been planned and implements in accordance with the accreditation requirements and
policies of the Accreditation Council for Continuing Medical Education through the joint providership of the
American Association of Oral and Maxillofacial Surgeons and the Southwest Society or Oral and
Maxillofacial Surgeons, Texas Society of Oral and Maxillofacial Surgeons, Midwestern Chapter of Oral and
Maxillofacial Surgeons and the Oklahoma Society of Oral and Maxillofacial Surgeons. The American
Association of Oral and Maxillofacial Surgeons is accredited by the ACCME to provide continuing medical
education for physicians.
The American Association of Oral and Maxillofacial Surgeons designates this live activity for a maximum of
16 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with their extent
of their participation in the activity.
STUART LIEBLICH, DMD
FEATURED
SPEAKERS
Dr. Lieblich graduated from Rutgers University (Highest Honors, 1977) and the
University of Pennsylvania School of Dental Medicine (1981). He completed his
residency in oral and maxillofacial surgery at Kings County/Downstate Medical
Center in New York. In 1984 he assumed a full-time position on the faculty of the
University of Connecticut until 1988. Currently, he is in private practice in Avon, CT
and maintains a part-time teaching appointment at the university as Clinical
Professor. At the University of Connecticut he lectures to the medical and dental
students on head and neck anatomy (with special focus on the
temporomandibular joint and the anatomy of orthognathic surgery) and also to
the various postgraduate residency programs. He is on the medical staff at
Hartford Hospital, Connecticut Children’s Medical Center, St. Francis Hospital, John
Dempsey Hospital (University of Connecticut Health Center) and Charlotte Hungerford Hospital (head, section of
oral and maxillofacial surgery).
Dr. Lieblich has been a contributor to over 20 textbooks and recently co-authored the textbook Anesthesia
Complications in the Dental Office with Dr. Bosack. He has published over 45 peer reviewed papers and abstracts.
He is an invited speaker at conferences throughout the United States and has presented his research at
international scientific meetings with focuses on ambulatory anesthesia, dental implants, dentoalveolar surgery
and periapical surgery. Previously he has served as a director and president of the American Dental Society of
Anesthesiology and following a 6-year term as a member of the examination committee of the American Board of
Oral and Maxillofacial Surgery (chair of the medicine and anesthesia sections) he was elected to an eight year term
of the ABOMS board of directors (President 2009-2010). Dr. Lieblich is on the editorial boards of the journals
Anesthesia Progress; Oral Surgery, Oral Medicine Oral Pathology (“Triple O”) and the Journal of Oral and
Maxillofacial Surgery (section editor, Anesthesia/facial pain). He regularly reviews articles for the International
Journal of Oral and Maxillofacial Surgery, and General Dentistry. Dr. Lieblich serves on many local, state and
national committees in his specialty and currently is a member of the American Dental Association’s Commission
on Accreditation (oral and maxillofacial surgery) and the co-chair of the American Association of Oral and
Maxillofacial Surgeons Parameters of Care Committee. He is currently a co-PI on a national multicenter study on
the use of antibiotics for elective oral surgical procedures.
This speaker has disclosed the following relationships: Pierrel Pharma, speakers' bureau; Pacira Pharma,
consultant.
MICHAEL S. BLOCK, DMD
FEATURED
SPEAKERS
Dr. Block graduated from the University of Rochester in 1975, attaining both a BA in Biology
and a BS in Biomedical Engineering. He completed his dental training at the Harvard School
of Dental Medicine in 1979, receiving his D.M.D. cum laude in a special field. He completed
his residency program in Oral and Maxillofacial Surgery at the LSU School of Dentistry in
1983. He remained at the LSU School of Dentistry and achieved the academic rank of
Professor in the Department of Oral and Maxillofacial Surgery. Currently he is in private
practice dedicated to patient oriented care.
Dr. Block is the editor-in-chief of five textbooks on dental implants, Endosseous Implants for
Maxillofacial Reconstruction, Implants in Dentistry, Color Atlas of Dental Implant Surgery:
the 4th edition was published in 2014. He is Past President of the Academy of
Osseointegration, and has been program chairman for three of their annual programs. Dr.
Block serves on the American Association of Oral and Maxillofacial Surgeons (AAOMS) Committee on Continuing
Education. Dr. Block has been an examiner for the American Board of Oral and Maxillofacial Surgery. He is a Section
Editor on Dental Implants for the Journal of Oral and Maxillofacial Surgery.
Dr. Block is particularly interested in the translation of technology for efficient and predictable reconstruction of the
jaw to provide ideal bone for implant placement and esthetic replacement of missing teeth, the use of multiple
techniques and implants to reconstruct significant atrophic conditions, and interceptive strategies for rehabilitating
extraction sites with implant restorations.
This speaker has disclosed the following relationships: X-Nav, stocks/bonds; Implant One, consultant.
COLIN S. BELL, DDS, MSD
A Dallas area native and Phi Beta Kappa graduate of Southern Methodist University, Dr. Bell
received his dental degree in 1979 from the Baylor College of Dentistry, and completed
Oral and Maxillofacial Surgery training at Baylor University Medical Center in 1984.
As an active member of the American Dental Association and the American Association of
Oral and Maxillofacial Surgeons, he currently serves as a senior delegate from Texas in the
AAOMS House of Delegates. He has previously completed terms as president of both the
Texas Society of Oral and Maxillofacial Surgeons and the Southwest Society of Oral and
Maxillofacial Surgeons. Most recently Dr. Bell served as the Chairman of the Oral and
Maxillofacial Political Action Committee Board of Directors, and thereafter was elected as a
Director of the American Board of Oral Maxillofacial Surgery and he recently completed his
term as president of the ABOMS board of directors. In September 2016, Dr. Bell was elected as a member of the
OMSNIC board of directors. In 2013, he received the AAOMS Presidential Achievement Award.
Dr. Bell serves as a Clinical Professor of Oral and Maxillofacial Surgery at Baylor College of Dentistry; Texas A&M
University Health Center. He holds fellowship status in both the American and International College of Dentists.
Dr. Bell maintains an active private practice. He is married and has two sons. He enjoys all types of outdoor activities,
snow-skiing and woodworking.
All reported relevant conflicts of interest have been resolved by the planning committees as of 1/1/2017.
ALUMNI
EVENTS
On Friday evening, Baylor Oral and Maxillofacial Surgeon’s Alumni Association (BOMSAA), the
University of Texas Health Science Center San Antonio Alumni Organization (UTHSC-SA
Alumni) and the University of Oklahoma Alumni (OUHSC OMS Alumni) in conjunction with the
Oklahoma Society of OMS will have a special dinner on resort property to celebrate the rich
history and successes of each residency program. Each dinner will begin at 7:30pm
immediately following the Friday evening Southwest Society reception. Special locations and
menus will be provided for this event.
-Don’t see your Alumni listed? If you are interested in starting an alumni dinner at the annual
meeting, contact the SWSOMS Executive Director for more information.
Gainey Ranch Golf Course
GOLF
TOURNAMENT
Gainey Ranch Golf Club
Thursday, April 20, 2017
Shotgun Start 1:30pm
$225 person
(Includes Green Fee & cart fee)
$70 club rental
Play one of the top rated golf courses in the country, exclusively available only to private club
members and the guests of Hyatt Regency Scottsdale Resort & Spa. Surrounded by incredible scenery,
Gainey Ranch Golf Club offers an exciting year-round challenge for golfers of any skill level. Each of the
three distinct nine-hole courses of our Scottsdale Arizona golf resort, designed by Benz and Poellot,
offers a different experience for players. Enjoy a special Arroyo/Lakes Combination round!
•
•
The Lakes features varied terrain in a garde-like setting and plays around a variety of water
features.
Arroyo, the longest and most open course, features a meandering desert wash that provides a
natural hazard throughout the nine.
PRESIDENT’S
EVENT
Saturday
April 22, 2017
Come Celebrate!
We invite you to enjoy an evening of dinner and
entertainment at the Beautiful Hyatt Regency Scottsdale
at Gainey Ranch Resort and Spa. Relax and enjoy the
natural surroundings and spectacular views of the
McDowell Mountain range from the Terrace Court while
listening to the talented Carlos Martinez and The Phat
Kats.
COMPANION
PROGRAM
Friday
April 21, 2017
Plants & People of the
Sonoran Desert Tour
Step off of our main trail onto the Plants and People of the Sonoran Desert Trail, which is one of the
largest exhibits of its kind dedicated to helping people understand the complex cultural relationships
between people and plants of the region. The trail winds through five habitats that have provided
people with useful plants for food, fiber, medicine and cultural purposes for 2,000 years: Desert,
Desert Oasis, Mesquite Bosque, Semi-desert Grassland and Chaparral. The story of these
relationships is brought to life through cultural examples of the Akimel O’odham and Western
Apache Roundhouse which you can explore. Also try hands-on activities such as pounding mesquite
beans to make flour. Please note this trail is on a dirt path and requires a large amount of walking.
1.5 Hour Tour followed by brunch at Gertrude’s Restaurant on site.
AGENDA
April 20, 2017 – Thursday
8:00am – 9:30am
9:30am – 10:30am
9:30am – 10:30am
10:30am – 12:00pm
10:30am – 12:00pm
1:30pm – 5:00pm
5:30pm – 7:30pm
SWSOMS Board of Directors Meeting
TOMSPAC Board of Directors Meeting
MIDWESTERN Chapter Board of Directors Meeting
TSOMS Board of Directors Meeting
OKLAHOMA Society Board of Directors Meeting
GOLF TOURNAMENT
WELCOME RECEPTION
April 21, 2017 – Friday
7:00am – 8:00am
8:00am – 12:00pm
9:30am – 1:00pm
1:00pm - 5:00pm
5:30pm – 7:00pm
7:30pm – 10:00pm
Continental Breakfast in Exhibit Area
BYRD-TILSON-WALKER RESIDENTS’ PRESENTATIONS
Companion Program- “The Plants & People of the Sonoma
Desert Tour” followed by brunch at Gertrude’s
REICHMANN LECTURE: Anesthesia Focus: “ Ambulatory
Anesthesia: Care Based Focused review of Techniques and
Complications”
Stuart E. Lieblich, DMD
EVENING RECEPTION
BOMSAA, UTHSCSA & OUHSC /Oklahoma Society Alumni Dinners
April 22, 2017 – Saturday
7:00am – 8:30am
8:00am – 12:00pm
12:00pm – 12:30pm
12:30pm – 1:30pm
12:30pm – 1:30pm
1:30pm – 5:30pm
7:00pm – 11:00pm
Continental Breakfast in Exhibit Area
KEYNOTE LECTURE: Michael S. Block, DMD
SWSOMS Membership Meeting
TSOMS Membership Meeting
OKLAHOMA Society Membership Meeting
OMSNIC Risk Management: Colin S. Bell, DDS, MSD
PRESIDENT’S EVENT
ONLINE Registration Opens Monday, January 23, 2017!
http://www.regonline.com/SWSOMS17
HOTEL
ACCOMMODATIONS
Hotel Accommodations
Group Rates Expire
March 20, 2017!
Discover the infinite beauty and natural
wonders of the Sonoran Desert surrounding
our breathtaking 27-acre Scottsdale hotel in
Arizona. Set amidst flowering cactus and
framed against the majestic McDowell
Mountains, this resort and spa is minutes
from outdoor adventures and miles from
the ordinary. Enjoy stunning views blended
with intriguing Native American culture, as
you indulge in our lifestyle amenities.
Hyatt Regency Scottsdale Resort & Spa
at Gainey Ranch
For reservations call: Hyatt Regency Scottsdale
Reservations 1-480-444-1234 or
log onto
https://aws.passkey.com/event/14234015/owner/6765/home
(group code not required)
Group Rates starting at $329 expire March 20, 2017
Scottsdale, Arizona
The month of April in Scottsdale, Arizona is characterized by rising daily
high temperatures, with daily highs increasing from 78°F to 86°F over
the course of the month, exceeding 96°F or dropping below 67°F only
one day in ten. The period between April and May is characterized
more by spring conditions. Thus, days are warm and with a humid,
temperate climate.
Transportation:
Air
Phoenix Sky Harbor Airport is just a short ride to the Hyatt Regency Scottsdale Resort & Spa at Gainey Ranch,
and offers jet service from most major Airlines including American Airlines, Southwest Airlines and United
Airlines.
Car Service
To / From Sky Harbor International Airport
Transtyle Sedan and SUV Service – offers 24-hour private chauffer driven services in sedans that can
accommodate up to four passengers and luggage, and SUV’s that can accommodate up to six passengers and luggage.
Transtyle also offers Van’s, Stretch Limousines, thirty two passenger Mini Buses, and full size fifty six passenger Motor
Coach’s. Advance reservations required. Cost: $50 Call upon arrival for your car to pick you up. $75 Meet and Greet
Service - have a car waiting for you upon arrival. SUV Request is an additional $20. Reservations: Call 800 410 5479
**Please note: Do not offer car seat options.
Super Shuttle offers transportation between the airport and the hotel 24 hours a day. Upon arrival at the airport,
look for the island marked Van Service outside of baggage claim. A uniformed Guest Service Representative will assist
you with your arrangements to the hotel. No advance reservations are needed from the airport to the hotel; however,
24 hour advance notice is requested for return trips from the hotel to the airport. Please note: Cost: $22 per person,
each way. Groups may reserve an entire shuttle for $80. Vans accommodate a maximum of seven people.
Reservations: Call 800 730 9267
**Do not offer car seat options.
Driving
From Phoenix Sky Harbor Airport:
Exit the airport following the signs to the 202 East. Take the 202 East to the 101 North. Continue on 101 North to the
Via De Ventura Exit and make a left. Travel West for approximately 2.5 miles (Via De Ventura turns into Doubletree
Ranch Road). Our Scottsdale AZ resort will be on the right side just before Scottsdale Road. (approximately 18 miles –
drive time: approximately 20 mins)
ONLINE Registration Opens Monday, January 23, 2017!
http://www.regonline.com/SWSOMS17
ONLINE Registration Opens Monday, January 23, 2017!
http://www.regonline.com/SWSOMS17
MEETING
REGISTRATION
April 20-23, 2017
Registration includes all general CDE/CME sessions, continental breakfast/breaks, entrance to Exhibit Hall, Thursday’s Welcome Reception
and Friday’s Evening Reception. Meeting cancellation is 100% refundable prior to February 14, 2017, 50% refundable if cancelled between
February 15, 2017 and March 20, 2017. No refund will be due for cancellations received after March 20, 2017:
Standard Registration:
_____$1250.00
SWSOMS RETIRED Social Registration
_____$600.00
Presenting Resident Registration:
_____ $0.00
**Saturday Evening Event not included in meeting registration
**Includes Receptions and Exhibit Hall Entrance, no CDE/CME functions
**One Ticket to the President’s Event Saturday Evening Included
Non-Presenting Resident Registration:
_____ $600.00
**Saturday Evening Event not included in meeting registration
Military / Active Duty Registration:
_____ $450.00
**Saturday Evening Event not included in meeting registration
Additional Opportunities Ticketed Separately:
Golf Tournament, Thursday, 4/20/17 ** green fee & cart fee
Golf Fee
_____player(s) x$225
Club Rental:
_____player(s) x$70
Please circle preference: Men’s / Women’s
Right / Left Handed
Companion Program “Plants & People of the Sonoran Desert Tour”
(brunch included), Friday, 4/21/17
_____ person(s) x $125
BOMSAA Dinner, Friday, 4/21/17
_____ person(s) x $150
UTHSC-SA Alumni Dinner, Friday, 4/21/17
_____ person(s) x $150
OUHSC / Oklahoma Society Alumni Dinner,
Friday, 4/21/17
_____ person(s) x $150
President’s Event, Saturday, 4/22/17
**Saturday evening tickets sold separately
_____ person(s) x $165
TOTAL DUE:
Contact Information
Name__________________________________________
E-mail__________________________________________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
$__________
Payment Instruction
Make Checks Payable to SWSOMS
All Major Credit Cards Accepted
MasterCard Visa Discover American Express
Fax Number: ______ - ___________________
Preferred Name for Badge_________________________
Spouse / Companion Information
Card Number___________________________________________
Expiration Date____________________CVV Code____________
Billing Address Zip: _____________________________________
Name__________________________________________
Preferred Name for Badge_________________________
Registration can be: Faxed: 210-614-3915(secure line)
Name on Card___________________________________________
Signature_______________________________________________
-or-
Mailed: SWSOMS
4499 Medical Drive, Suite #190
San Antonio, TX 78229