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This form is for
NEW
accounts only.
If this is a renewal, please click on the Renew tab.
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
*
$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
*
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
*
Price:
$400.00
($1500 per site)
Subtotal:
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
CAPTCHA
65930