Vascular Birthmarks Foundation 2018 Conference

2018 Conference Graphic

2018 VBF Annual Conference and Clinic

with the Lenox Hill Hospital and
Dr. Robert Rosen, Dr. Milton Waner,
Dr. Francine Blei, and Dr. Roy Geronemus

October 6, 2018 | New York, NY

 

 

REGISTRATION FORM

 

Please complete the form below to register for the 2018 VBF Conference and Clinics in New York, NY on October 6, 2018.  
 

BEFORE YOU BEGIN:  

  • A photo of the patient’s vascular birthmark or birthmark-related syndrome is required to complete this registration; please have a digital image available to upload. Those who do not provide a photo will not be eligible to be considered for clinical appointments or to be considered for a free hotel room.
  • The $100 per patient conference registration fee includes all conference and special sessions, clinic appointments (if available), breakfast and lunch for the patient and accompanying persons, daycare (if needed), and one night of lodging for those who qualify and are deemed eligible. Those who request a waiver for financial hardship will be required to pay a $25 processing fee.
  • For those selected for a free hotel room, incidentals will be charged to the guest credit card on file.  Guests must provide the hotel with a personal credit card for incidental charges upon check in.  Any hotel guests who do not attend the conference and neglect to cancel within the normal cancellation window, or who stays in a hotel room but does not attend the conference, will be charged by the hotel for the full rate of the room, tax and any related charges.
  • Only 50 free hotel rooms are available. Those not selected for a free hotel room are independently responsible for all of their own lodging costs and arrangements.

All questions and conference correspondence will be directed to the PRIMARY CONTACT identified immediately below; please identify an adult over the age of 18.

 

All fields marked with an asterisk (*) are required.

 

 
 
Yes, I’d like to opt in to receive occasional updates about VBF’s work with the birthmark community, the latest in research and treatment methods, fundraising appeals, and opportunities to support VBF’s awareness mission. You can change your mind at any time by emailing birthmark.org@gmail.com.
Event Fee(s)
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Billing Name and Address
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To be considered for a free hotel room, you must provide a photo showing a visible birthmark, or medical documentation with the name of patient as to a non-visible birthmark, and be located outside the NYC Metropolitan Area. Guests will be required to provide a credit card upon check in to the hotel to cover any incidental charges. Any hotel guests who do not attend the conference and neglect to cancel within the normal cancellation window, or who stays in a hotel room but does not attend the conference, will be charged by the hotel for the full rate of the room, tax and any related charges. We will contact you with further information if you are selected for a free hotel room. Only 50 free hotel rooms are available. Those not selected for a free hotel room are independently responsible for all of their own lodging costs and arrangements.


Section 1: Patient Details



 
 
Yes indicates consent for VBF to use image in future conference materials or on any VBF-owned website.
 

Section 2: Patient Medical Background


NOTE: Include name, practice, and contact information
Upload a clear photograph of the patient's birthmark. If internal or in a sensitive area, substitute a clear photo
of the patient for identification and we will contact you regarding images of the birthmark or lesion.
We cannot proceed with registrations without a photo.

Section 3: Clinic and Special Session Appointments


Dental and orthodontic exams will be subject to qualification and availability. Note that dental and orthodontic exams, if offered, will be held on Friday, October 5, on the day before the Conference at an off-site location in New York, New York. If you are eligible, we will contact you with further information about offerings and instructions as the examination schedule is finalized.
 
To be considered for a free laser treatment, you must provide a photo showing a laser accessible birthmark, not be a current patient of Dr. Geronemus’ practice, and must agree that there will be no anesthesia. Dr. Geronemus' office will screen and approve all candidates for free treatment. If you are scheduled for a free laser treatment appointment and fail to cancel it within 48 hours of the assigned treatment, you will be charged $500, as these are very important slots for a free treatment that we want to ensure are utilized. We will contact you will further information if you are deemed eligible.
All afternoon appointments will be assigned to avoid time conflicts and in consideration of travel plans. Please advise of any additional time conflicts due to travel (e.g. early flights) or other obligations (e.g. infant nap times, etc).

Section 4: Accompanying People


Accompanying Person #1
 
 
 
Yes indicates consent for VBF to use image in future conference materials or on any VBF-owned website.


Accompanying Person #2
 
 
 
Yes indicates consent for VBF to use image in future conference materials or on any VBF-owned website.


Accompanying Person #3
 
 
 
Yes indicates consent for VBF to use image in future conference materials or on any VBF-owned website.

Section 5: Conference Promotion



Section 6: Fill this in ONLY if you are requesting a waiver of conference fees