Registration
 Registration fee is $50 for Attending Physicians
 Fee is waived for Residents and Fellows
*OTS Membership Fee will be waived for the current year for all conference attendees.
Please mail or fax registration form to:
Oklahoma Thoracic Society
Attention: Delisa McKinzie
920 Stanton L Young Blvd, WP 1310
Oklahoma City, OK 73104
Fax: 405.271.5892
Confirmation
A confirmation letter will be sent by email.
Contact Information
Delisa McKinzie
Delisa-McKinzie@ouhsc.edu
Phone: 405.271.6173
Fax: 405.271.5892
http://www.oklahomathoracic.org
Accreditation Statement:
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the
Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Oklahoma
College of Medicine and the Oklahoma Thoracic Society. The University of Oklahoma College of Medicine is accredited by the
ACCME to provide continuing medical education for physicians.
The University of Oklahoma College of Medicine designates this live activity for a maximum of 9.25 AMA PRA Category 1
Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Conflict Resolution Statement:
The University of Oklahoma College of Medicine, Office of Continuing Professional Development has reviewed this activity’s
speaker and planner disclosures and resolved all identified conflicts of interest, if applicable.
Acknowledgement of Commercial and In-Kind Support:
Commercial support is financial, or in-kind, contributions given by a commercial interest, which is used to pay all or part of the
costs of a CME activity. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods
or services consumed by, or used on, patients. The ACCME does not consider providers of clinical service directly to patients to
be commercial interests.
This conference has received in-kind support from the State of Oklahoma – University Hospitals Authority & Trust and GE
Healthcare.
Nondiscrimination Statement:
The University of Oklahoma, in compliance with all applicable federal and state laws and regulations does not discriminate on the
basis of race, color, national origin, sex, sexual orientation, genetic information, gender identity, gender expression, age, religion,
disability, political beliefs, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to:
admissions, employment, financial aid, and educational services.
Accommodation Statement: For accommodations on the basis of disability, call: 405.271.6173.
Policy on Faculty and Joint Provider Disclosure:
It is the policy of the University of Oklahoma College of Medicine that the faculty, presenters and joint providers disclose real or
apparent conflicts of interest relating to the topics of this educational activity, and also discloses discussions of unlabeled/
unapproved uses of drugs or devices during their presentation(s).
Disclaimer Statement:
Statements, opinions and results of studies contained in the program are those of the presenters, authors and joint provider and
do not reflect the policy or position of the Board of Regents of the University of Oklahoma (“OU”) nor does OU provide any
warranty as to their accuracy or reliability.
Every reasonable effort has been made to faithfully reproduce the presentations and material as submitted. However, no
responsibility is assumed by OU for any claims, injury and/or damage to persons or property from any cause, including
negligence or otherwise, or from any use or operation of any methods, products, instruments or ideas contained in the material
herein.
Registration Form
Oklahoma Thoracic Society
November 19-20, 2015
Please print
Title (select one): Dr. Mr. Mrs. Ms.
Name (First, Middle, Last): ______________________________________________________________________
Degree: ________________ Specialty: ____________________________________________________________
Profession: Attending Physician Physician in Training
Organization: ________________________________________________________________________________
Home Address: ______________________________________________________________________________
City: ____________________________________________ State: __________ Zip: _____________
Work Phone: _________________________ Cell: _________________________ Fax: ______________________
Email Address: (required for receipt confirmation) ____________________________________________________
I plan to attend:
Symposium on Bedside Ultrasound in Critical Care on November 19, 2015
The Hammarsten Pulmonary Conference on November 20, 2015

I will I will not be requesting CME.
$50
Residents/Fellows Fee is Waived
Amount Enclosed: $__________________
Payment: Cash Check
Credit Card Information: VISA
MasterCard
Card # Exp. Date: _____________________________________________
Name on Card: _______________________________________________
I would like to become a member of the Oklahoma Thoracic Society. I understand that my dues will be
waived this year for attending this conference.
Please make checks payable to Oklahoma Thoracic Society and mail or fax registration form to:
Oklahoma Thoracic Society
Attention: Delisa McKinzie
920 Stanton L Young BLVD, WP 1310
Oklahoma City, OK 73104
Fax: 405.271.5892