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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
$1500 one-time retainer fee for DUA processing; the total final cost ranges from $1500 to approximately $3000 and is dependent on the time spent negotiating revisions to the standard CESQIP DUA. The ESQ Foundation will balance bill each program the difference at the time of account activation.
International Programs Enrollment Options
Full CESQIP Access: $1000 per site per year
- (Includes access to Thyroid, Parathyroid, Adrenal, PNET and GINET modules)
Thyroid and Transoral Endoscopic Thyroid (TOETVA) Module only: $500 per site per year
Latin America CESQIP (site must be approved by LA CESQIP champion; email cesqiphelp@cesqip.org for more information)
There is no administrative or DUA fee for international programs

Name*

First Last

Are you based in the United States?*

Yes
No

Please categorize your international CESQIP participation:*

Full CESQIP Access
I am a member of Latin American CESQIP
I am a participant in the Thyroid and TOETVA Best Practice Module Only

Phone*

Phone (International)*

Email Address*

Name of Program or Primary Hospital*

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*

Address For Legal Documents*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

In how many facilities do you wish to collect CESQIP data?*

Please enter a number from 1 to 99.

Please list the name of each facility where you wish to collect CESQIP data*

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.

Total Number of Physicians In Program*

Please list the total number of physicians in your program, across all sites.

Total Number of Physicians In Program*

Please list the total number of physicians in your program, across all sites.

Annual Administrative Fee*

Price:

DUA Fee*

Price: $400.00

($1500 per site)

Subtotal:

I would like to pay by*

Mail a check

Total

$0.00

Credit Card Convenience Fee*

Price: $0.00

Credit Card Convenience Fee*

Price: $0.00

Total (including credit card convenience fee)

$0.00

Credit Card*

Card Details

Cardholder Name

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This form is for NEW accounts only. If this is a renewal, please click on the Renew tab.

Vision

Contact Us

Site Map

This form is for NEW accounts only.
If this is a renewal, please click on the Renew tab.