International Pediatric Endosurgery Group

Advancing Pediatric Endosurgery Around The World

International Pediatric Endosurgery Group

Advancing Pediatric Endosurgery Around The World

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Are you still in your surgical training?*
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- I am not a surgeon
What is your country of residence?*
Member Category*

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Member Type*
Name*
First (Personal) Middle Last (Family)
Degrees*
MD, PhD, etc.
Title/Department
Hospital/Institution
Mailing Label*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone*
Mobile Phone
Fax
Email*
Date of Birth*
Date Format: MM slash DD slash YYYY
Country of Birth*
When do you expect to complete your training?*
Date Format: YYYY slash MM slash DD
License and Certification Information
Do you have a medical license?*
- Yes
- No
Issued by*
Registry #*
Expiration Date*
Date Format: YYYY slash MM slash DD
Board Certification
Are you Board Certified?*
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Certifying Body*
Certificate #*
Expiration Date*
Date Format: YYYY slash MM slash DD
Practice Pattern
Academic Affiliations
Institution Title
Hospital Affiliations
Institution Title
Current Society Memberships*
- APSA
- SAGES
- EAES
- PAPS
- AAPS
- Other
- None
Other Society Memberships*
Education Topics of Interest
- Basic Science
- Oncology
- Colon/Bowel
- Fetoscopy
- Foregut
- Genito-urinary
- Instrumentation
- Neonatal
- Neurosurgery
- Orthopedics
- Otolaryngology
- Robotics/Single Site
- Spleen/Solid Organ
- Telementoring
- Thoracoscopy
- Other
Other Education Topics of Interest*
Background Information
Undergraduate Education
Institution Degree Obtained Years Attended
Medical/Nursing School
Institution Degree Obtained Years Attended
Internship
Institution Degree Obtained Years Attended
Other Applicable Training
Institution Degree Obtained Years Attended
Primary Health Specialty
- Basic Science
- Oncology
- Colon/Bowel
- Fetoscopy
- Foregut
- Genito-urinary
- Instrumentation
- Neonatal
- Neurosurgery
- Orthopedics
- Otolaryngology
- Robotics/Single Site
- Spleen/Solid Organ
- Telementoring
- Thoracoscopy
- Other
Other Primary Health Specialty
Please describe your current position

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Please choose a dues option:*
- I'd like to pay only my first year of dues today.
- I'd like to pay 3 years of dues today at a 25% discount.
Surgeon Tier 1*
Price: $300.00
Surgeon Tier 1 - 3 Years Discounted*
Price: $675.00
Surgeon Tier 2*
Price: $250.00
Surgeon Tier 2 - 3 Years Discounted*
Price: $562.50
Surgeon Tier 3*
Price: $200.00
Surgeon Tier 3 - 3 Years Discounted*
Price: $450.00
Surgeon-In-Training*
Price: $95.00
Surgeon-In-Training - 3 Years Discounted*
Price: $213.75
Allied Health*
Price: $140.00
Allied Health - 3 Years Discounted*
Price: $315.00
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Total
$0.00
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Name
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CONTACT IPEG:

11300 W. Olympic Blvd., Suite 600
Los Angeles, CA 90064, USA

Phone: +1-310-437-0553
Fax: +1-310-437-0585

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