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Endocrine Surgery Quality Foundation
838 E High St, # 140
Lexington, KY 40502
US Programs
$200 Administrative fee per program
$1300 for one physician, $2300 for two physicians with a $2800 maximum at an program for 3 or more physicians
International Programs
$200 Administrative fee per program
$1000 per year per site
Name
*
First
Last
Are you based in the United States?
*
Yes
No
Phone
*
Phone (International)
*
Email Address
*
Name of Program or Primary Institution
*
Name of CESQIP Physician Champion at your site?
*
First
Last
Physician Champion phone
*
Physician Champion phone (Int'l)
*
Physician Champion email
*
Name of CESQIP Administrative Champion at your site?
*
First
Last
Administrative Champion phone
*
Admin. Champion phone (Int'l)
*
Administrative Champion email
*
In how many new facilities (if any) do your program’s surgeons perform endocrine surgery procedures?
*
0
1
2
3
4
5
6
7
8
9
Please list the name(s) of each new facility/hospital in your program
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Site Name
*
Does this facility have a Data Use Agreement with CESQIP?
*
No
Yes
Not Required
Please list all CESQIP participants at your program
*
Participant Name
Email Address
Please include surgeons, administrators, fellows, etc.
To add another participant, click the (+) button.
Please be accurate, as non-listed accounts will be de-activated.
I would like to pay by
*
Mail a check
I am a member of Latin American CESQIP (no payment due)
Total Number of Physicians In Program
*
$1,300 - One Physician
$2,300 - Two Physicians
$2,800 - Three or More Physicians
Please list the total number of physicians in your program, across all sites.
Total Number of Physicians In Program
*
$1,300 - One Physician
$1,300 - Two Physicians
$1,300 - Three or More Physicians
Please list the total number of physicians in your program, across all sites.
Total Number of Physicians In Program
*
One Physician
Two Physicians
Three or More Physicians
Please list the total number of physicians in your program, across all sites.
Annual Administrative Fee
*
Price:
DUA Fee:
Subtotal:
Subtotal:
Credit Card Convenience Fee
*
Price:
$0.00
Credit Card Convenience Fee
*
Price:
$0.00
Total (including credit card convenience fee)
$0.00
Total
$0.00
Credit Card
*
Card Details
Cardholder Name
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