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S ituated within the Allegheny Mountains, the landscape surrounding the iconic and historic Homestead Resort provides a stunning backdrop for doctors to earn continuing education credit, chiro- practic office staff to enhance job skills, and all to expand horizons, make connections, get inspired and have a great time. Over 17 CEUs for DCs, including over 15 Type 1! (VA, MD, DC; contact UVCA office for other states) Over 17 hours of compre- hensive, professional staff training. The topics and speakers you’ve asked for. Plus: Exhibits Great rates on luxurious rooms Silent Auction Indoor and outdoor pools featuring radiant heat and spring-fed waters Spa and Spa Garden High tea Tennis Golf for adults and kids Zip lines Horseback riding and carriage rides Hiking, fishing, mountain biking Falconry Game room Nightly movies Dancing Playground Restaurants and pubs for all tastes and budgets More e Unified Virginia Chiropractic Association’s Spring Convention Closer Than You Think! Approx. driving times: Roanoke - 1.25 hours Richmond - 3 hours Charlottesville - 2 hours Norfolk - 4.25 hours Fairfax - 3.5 hours May 18-20, 2018, e Omni Homestead Resort, Hot Springs, VA Comaraderie Connections Clinical Skills CEUs Staff Training Rejuvenation Fun! Early-bird Discount Expires March 15 th !

The Unified Virginia Chiropractic Association’s Spring ... · In his back-to-basics approach, he whittles a difficult subject ... chiropractor can use to achieve this result. One

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Page 1: The Unified Virginia Chiropractic Association’s Spring ... · In his back-to-basics approach, he whittles a difficult subject ... chiropractor can use to achieve this result. One

Situated within the Allegheny Mountains,

the landscape surrounding the iconic and historic Homestead Resort provides a stunning backdrop for doctors to earn continuing education credit, chiro-practic office staff to enhance job skills, and all to expand horizons, make connections, get inspired and have a great time.

Over 17 CEUs for DCs, including over 15 Type 1!(VA, MD, DC; contact UVCA office for other states)

Over 17 hours of compre-hensive, professional staff training.

The topics and speakers you’ve asked for.

Plus:• Exhibits• Great rates on

luxurious rooms• Silent Auction• Indoor and outdoor

pools featuring radiant heat and spring-fed waters

• Spa and Spa Garden• High tea• Tennis• Golf for adults and kids• Zip lines• Horseback riding and

carriage rides• Hiking, fishing,

mountain biking• Falconry• Game room• Nightly movies• Dancing• Playground• Restaurants and pubs

for all tastes and budgets

• More

The Unified Virginia Chiropractic Association’s

Spring Convention

Closer Than You Think!Approx. driving times:Roanoke - 1.25 hoursRichmond - 3 hours

Charlottesville - 2 hoursNorfolk - 4.25 hoursFairfax - 3.5 hours

May 18-20, 2018, The Omni Homestead Resort, Hot Springs, VA

Comaraderie

Connections

Clinical Skills

CEUs

Staff Training

Rejuvenation

Fun!Early-bird DiscountExpires March 15th!

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DC ProgramFriday, May 18

Morning Come in early for a Gorge Hike, History Tour, Golf, Zip Line Adven- ture or much more before the convention begins! 2:00-6:00pm Professional & Sexual Boundaries by Dr. Mario Fucinari OR New Trends in the Prevention of Running Injuries by Dr. Kevin Maggs OR The Interference Principle by Dr. Eric Plasker3:00-6:30pm Exhibitor Set-Up6:00-7:00pm Profession Updates, Lifetime Care Research Project7:00-7:30pm Welcome Reception with Exhibitors

Saturday, May 197:30-8:00am Cont’l Breakfast, Exhibit Viewing, Silent Auction Opens8:00-10:00am Start of Measuring Objective Criteria for the Wellness-based Practice by Dr. Dane Donohue OR Start of Physiotherapeutic Devices For Pain Relief & Tissue Healing by Dr. Nelson Marquina10:00-10:15am Break with Exhibitors10:15-11:45am End of Measuring Objective Criteria for Wellness-based Practice OR End of Physiotherapeutic Devices11:45am-12:45pm Profession Updates & Membership Meeting 12:45-2:00pm Lunch with Exhibitors OR New Member Lunch2:00-4:00pm Start of Neurology by Dr. Lisa Bloom OR Start of Documentation, Coding & Compliance by Dr. Mario Fucinari4:00-4:30pm Healthy Snack Break with Exhibitors4:30-6:30pm Cont. of Neurology OR End of Documentation6:30-7:00pm President’s Reception (By Invitation)

Sunday, May 207:30-8:00am Cont’l Breakfast, Exhibit Viewing, Silent Auction8:00-10:00am Cont. of Neurology OR Start of MPI Lumbopelvic Mobility & Stability by Dr. Mark King10:00-10:30am Break with Exhibitors & Final Silent Auction Bidding10:30am-12:30pm End of Neurology OR End of Motion Palpation12:30-1:00pm Last-Minute Exhibit Visits & Auction ReconciliationAfternoon Stay a little longer & book a spa treatment, hit a trail, enjoy a swim in the spring-fed pool, or more! A

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Professional & Sexual BoundariesFor DCs & CAsMario Fucinari, DC CCSP, APMP, CPCO, MCS-PSponsored by NCMIC

This session considers professional and sexual issues in the chiropractic office. Recent events have led to an acute awareness of physician

actions that may compromise the physician-patient relationship. The chiropractic practice is unique in that it frequently involves touching the patient. This can lead to situations that may arise to challenge legal, practical and cultural differences between the doctor, staff and patient. Ethical principles and models for decision making that are most applicable in the healthcare profession will be discussed. BIO: Dr. Fucinari has trained doctors and staff for over 20 years. He received his DC degree from Palmer in 1986. After graduating, Dr. Fucinari completed studies in chiropractic orthopedics and attained certifications in chiropractic sports, Insurance and Coding. Dr. Fucinari was awarded the prestigious 2012 Chiropractic Physician of the Year by the Illinois Chiropractic Society. He was the recipient of the ICS’ 1998 and 2003 President’s Award for his work in education. He has produced classes and publications on HIPAA, Clinical Documentation, Medicare, and Stroke and Cervical Manipulation and speaks worldwide. He is a member of the Carrier Advisory Committee for Medicare and practices full-time in Illinois.

The Chiropractic Guide to Documentation, Coding & ComplianceFor DCs, CAs, & BillersMario Fucinari, DC CCSP, APMP, CPCO, MCS-PSponsored by NCMIC

You have taken all the classes, but the rules have changed again - in ways that will impact the way you practice! This class shows you how to develop strategies to mitigate your risk associated with practice requirements and how to apply the scientific evidence to improve patient outcomes, without giving up your chiropractic roots. Learn what Medicare defines as an “episode of care”, billing and ICD-10 coding guideline updates, modifier use for chiropractic, the ABN form for par and non-par providers and front desk procedures for the office. In his back-to-basics approach, he whittles a difficult subject to an understandable and interesting comprehension of the requirements.

New Trends in the Prevention of Running InjuriesFor DCsKevin Maggs, DCSponsored byThe Running Clinic

Many beliefs pertaining to running injury prevention and management do not reflect the current scientific evidence. This presentation provides an update on the current literature surrounding prevention and treatment of running injuries. Topics include injury risk factors, gait evaluation, shoe prescription, injury management and running’s link with osteoarthritis. BIO: Dr. Maggs has been in practice since 1996. An ART instructor, he was the director for all Rev3 triathlons from 2009-2013, organized the ART team for the elite runners of the Armed Forces at the Marine Corps Marathon and has cared for the professional triathletes at the ITU World Championships in DC and for the USGA US Open. He owns and operates a small private practice in Northern Virginia, specializing in gait analysis and treating runners and triathletes ranging from beginners, to the world’s top professionals. Dr. Maggs has spoken on running biomechanics at a variety of venues ranging from at marathons to university programs. A regular runner and triathlete, he has completed several marathons and full distance triathlons.

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The Interference PrincipleFor DCs & CAsEric Plasker, DCSponsored by The Family Practice

Dr. Plasker provides the practitioner with a research-based framework for human perfor-mance and potential and identifies the role of nerve, lifestyle and environmental interference

on an individual’s health and quality of life. BIO: Dr. Plasker is a Life University graduate. After building up his 2nd Atlanta office to over 100 visits a day within 9 months, he began sharing his experience. In 2000 Dr. Plasker started The Family Practice, helping chiropractors grow their practices by millions of patients and half a billion dollars in collections with high integrity lifetime chiropractic care, patient education, marketing, business systems and procedures. Dr. Plasker has two international bestsellers, The 100 Year Lifestyle, an international bestseller that attracted people around the world to a new way of living and chiropractic, and The 100 Year Lifestyle Workout and The Longevity Solution

- Secrets of The 100 Year Lifestyle. Dr. Plasker speaks for companies, state, national and international associations, chiropractic colleges and universities. His progressive endeavors are relevant and effective for both new practitioners and the established doctor who wants to reach goals and be a more effective leader.

The Scientific Basis of Chiropractic CareFor DCsLisa Bloom, DC, PhDSponsored by Foot Levelers Inc.

Dr. Bloom provides a synopsis of peer-reviewed literature supporting chiropractic care and the neurological effects of the supporting the vertebral subluxation complex. Musculoskeletal

and reflexive non-musculoskeletal effects are discussed. Topics include immobilization degeneration, nociception versus pain and the neurology of pain, and the autonomic effects of nociception. Evidence to support the role of chiropractic care in pain management, non-musculoskeletal conditions

and in wellness care is discussed. BIO: Dr. Bloom is a Full Professor in the Clinical Sciences/Diagnosis Department, the Assistant Dean of Preclinical Chiropractic Education at New York Chiropractic College, and a Fellow of the International Academy of Chiropractic Neurology. She completed a PhD in Higher Education Leadership and holds a Diplomate and board certification from the International Board of Chiropractic Neurology and a Diplomate in Applied Chiropractic Sciences. Dr. Bloom has been the featured speaker at conferences in 46 states in the US, as well as a keynote speaker at many international conferences. A multiple winner of the Faculty Excellence Award, Dr. Bloom serves as a board member of the International Academy of Chiropractic Neurology and has served on the National Board of Chiropractic Examiners test writing committee. Dr. Bloom is the creator of the YouTube NeuroDocUniverse channel which is utilized worldwide and is focused on improving clinical mastery in neurological examination and diagnosis.

Measuring Objective Criteria for the Wellness-based PracticeFor DCs & CAsDane Donohue, DCSponsored by 8 Weeks to Wellness

Dr. Dane wants to change the face of healthcare in America by taking the focus off of sickness care and placing the emphasis on wellness care. Dr. Dane showd there are many tools a chiropractor can use to achieve this result. One such tool is the Wellness Score™, a multi-biomarker analysis for each patient, demonstrating that physiology dictates a wellness care plan, not symptomology. Dr. Dane feels that when doctors can show patients that what they need (functional care) is just

CA ProgramFriday, May 18

Morning Come in early for a Gorge Hike, History Tour, Golf, Zip Line Adven- ture or much more before the convention begins! 2:00-6:00pm Professional Boundaries by Dr. Mario Fucinari OR The Interference Principle by Dr. Eric Plasker3:00-6:30pm Exhibitor Set-Up6:00-7:00pm Profession Updates, Lifetime Care Research Project7:00-7:30pm Welcome Reception with Exhibitors

Saturday, May 197:30-8:00am Cont’l Breakfast, Exhibit Viewing, Silent Auction Opens8:00-10:00am Start of Measuring Objective Criteria for the Wellness-based Practice by Dr. Dane Donohue OR Efficient Appointment Scheduling & Handling Patient Excuses by Ms. Lisa Maciejewski-West10:00-10:15am Break with Exhibitors10:15-11:45am End of Measuring Objective Criteria for Wellness-based Practice OR New Patient Referrals & Reactivations by Ms. Maciejewski-West11:45am-12:45pm Profession Updates & Membership Meeting 12:45-2:00pm Lunch with Exhibitors; Silent Auction Shopping2:00-4:00pm Start of Documentation by Dr. Mario Fucinari OR Basic Anatomy for the Chiropractic Office by Dr. Tom Wetzen4:00-4:30pm Healthy Snack Break with Exhibitors4:30-6:30pm End of Documentation OR Chiropractic Philosophy by Dr. Wetzen

Sunday, May 207:30-8:00am Cont’l Breakfast, Exhibit Viewing, Silent Auction8:00-10:00am Start of Compliant Conversations for the Chiropractic Assistant by Ms. Kristi Hudson 10:00-10:30am Break with Exhibitors & Final Silent Auction Bidding10:30am-12:30pm End of Compliant Conversations for the CA12:30-1:00pm Last-Minute Exhibit Visits & Auction ReconciliationAfternoon Stay a little longer & book a spa treatment, hit a trail, enjoy a swim in the spring-fed pool, or more!

As of 1/25/18; Subject to Change Page 3

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Page 4

as important as what they want (symptomatic relief), a dramatic shift takes place in accepting the behavioral and financial responsibility that comes with truly being healthy. BIO: Dr. Dane Donohue has been in practice since 1991. He has been recognized by his peers with numerous national awards for practice excellence, including the Pennsylvania Chiropractic Association’s Chiropractor of the year in 2008. He is committed to the idea that all people deserve to be healthy, and their choices and behaviors ultimately determine their level of health. His role as a doctor is to inspire and educate people to make better choices that will lead to better health outcomes.

MPI Lumbopelvic Mobility & StabilityFor DCsMark King, DCSponsored by Anabolic Laboratories

Dr. King prepares chiropractors to utilize static and dynamic palpation assessments of spinal joints and surrounding soft tissues, posture, gait

and functional testing as part of a thorough examination. Emphasis will be placed on the interpretation of the assessment findings and how to correlate this information with other historical and examination data. Treatment options in the form of diversified adjustive procedures and rehabilitation methods of the lumbar spine and pelvis will be discussed and demonstrated. BIO: Dr. King is a cum laude graduate from Life Chiropractic College. He started the Mt. Lookout Chiropractic and Sports Injury Center with Dr. Donna Moloney in 1987. Dr. King has studied, lectured, and written extensively about spine and extremity injuries and treatment methods. Dr. King is currently the president and an instructor for the Motion Palpation Institute. He teaches classes throughout the world for MPI, which keeps him up to date on new diagnostic and treatment methods. He is a past president of the Southwestern Ohio Chiropractic Association and Chiropractic Choice.

Physiotherapeutic Devices For Pain Relief & Tissue HealingFor DCs & CAsNelson Marquina, DC, PhDSponsored byLaser Biotech International

This class provides the scientific, safety, regulatory, and illustrations/demonstrations

to ensure conference participants understand the potential benefits of combining electrotherapeutic devices in their practices. It focuses on the inclusion of TENS/microcurrent, ultrasound, lasers, and/or pulsed electromagnetic field devices to key treatment protocols in physical and sports medicine. It provides the foundation knowledge as applied to pain relief and tissue healing that are typically encountered in a chiropractic clinic. Participants learn the proper procedures following good clinical practices and meeting all Federal and State regulatory directives. BIO: Dr. Marquina is the Chief Technology Officer of Laser Biotech International Inc. and a developer of photonic and bioelectromagnetic systems and treatment protocols. He is the author of chapters in integrative health books in both the U.S. and Japan. Dr. Marquina conducts seminars

and research presentations in laser phototherapy and photobiology in North America, Asia and South America. He has taught laser biophysics, bioelectromagnetic medicine and artificial intelligence, as he served on the faculties of the University of Houston in Systems Engineering, the University of Rhode Island in Electrical Engineering, the University of Minnesota in Electrical Engineering, and the Virginia State University in Physics. He is a former Senior Scientist at NASA/Johnson Space Center and Director of Research at Logan University. He also held positions with GE, Honeywell and Lockheed Electronics in technology development and management. Dr. Marquina earned a BS in mathematics, a MS in statistics, and doctoral degrees in systems engineering from the University of Houston and in chiropractic medicine from Logan University. He is also certified to practice acupuncture in the state of Virginia.

Basic Anatomy for the Chiropractic OfficeFor CAsThomas Wetzen, DC

Increase your value to your patients, doctor and practice by learning or reviewing the key definitions, terminology and basic theme of anatomy. This information forms the basis of the complex structural details of the human body

that your doctor works with every day. Your grasp of the primary concepts will help you to better assist and communicate with your doctor and patients. BIO: Dr. Wetzen, a Life University, has been practicing chiropractic since 1989; first in South Carolina, then Virginia. Dr. Wetzen is the immediate past president of The Unified Virginia Chiropractic Association, VP of the East Coast Associations’ Independent Physicians Network, and district 3 representative for the Congress of Chiropractic State Associations. He is a Certified Chiropractic Sports Physician and has provided care for the Russian Olympic swim team prior to the 1996 Atlanta Olympics, as well as numerous high schools, colleges and professional athletes. He provided care for rescue personnel at the Pentagon following the 9/11 attack. He has received numerous honors from state associations, including Chiropractor of the Year, Service and Commitment, and Chiropractic Service awards.

Chiropractic PhilosophyFor CAsThomas Wetzen, DC

What is meant by “chiropractic philosophy?” What is the difference between Mechanistic and Vitalistic philosophies, where does your practice

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fit in – and why is it sometimes a sensitive issue between doctors? What is the difference between the allopathic medical model and what Doctors of Chiropractic do? Dr. Wetzen answers these questions and facilitates a balanced discussion on the relevance of chiropractic philosophy in your role as a chiropractic office team member.

Efficient Appointment Scheduling & Handling Patient ExcusesFor CAsLisa Maciejewski-West , CMC, CMOM, CMIS, MCS-PSponsored by Gold Star Medical Business Services

A well run schedule can mean the difference between a practice in chaos or calm efficiency. In this class we will explore efficient scheduling procedures, telephone scripts and how to handle the most common patient excuses, as well as barriers patients have that prevent them from keeping their appointments and showing up on time. BIO: After a 35 year career in the chiropractic, medical and dental fields, including 10 years as a senior practice consultant and speaker/trainer with one of the largest practice management firms in the US, Ms. Maciejewski-West founded Gold Star Medical Business Services in 2006. In addition to the Medical Billing division, Gold Star offers a variety of practice assistance and development services. Lisa is a Certified Medical Coder, Certified Medical Compliance Specialist and a Certified Medical Office Manager. She teaches medical coding and billing school “boot camps”, designed to introduce individuals to the career field of medical billing. She is a faculty member of Practice Management Institute, and teaches billing, coding, compliance and practice management classes and webinars to hospital and multi specialty provider groups nationwide. She speaks and teaches nationally at association meetings, events and conferences. Gold Star Medical has won numerous awards, including the Texas Governor’s Employer of the Year award in the Small Business Category, and the Small Business Administration’s “Women in Business Champion.”

New Patient Referrals & ReactivationsFor CAsLisa Maciejewski-West , CMC, CMOM, CMIS,MCS-PSponsored by Gold Star Medical Business Services

CAs are so much more than administrative assistants. In many cases, CAs are the face and soul of a practice. They can have a powerful impact in helping to generate patient referrals. In this class we will discuss ways CAs

Page 5

can plant referral seeds in both the practice and their community. We will also discuss implementing a systematic monthly reactivation program and quarterly reactivation campaigns.

Compliant Conversations for the Chiropractic AssistantFor CAsKristi Hudson, CPCOSponsored by ChiroHealthUSANon-compliance in healthcare can have very serious and sometimes devastating consequences. There has been an increase

in auditors and investigators disguising themselves as new patients in chiropractic offices across the country. Every conversation, starting with, “How much does it cost to see the doctor?” is now under scrutiny. It has never been more crucial to know what to say and when to say it when it comes to talking to patients about finances in your office. In this fast-paced and important training session, master communicator, Kristi Hudson will take team members through sticky scenarios that are encountered in practice every day. CAs will leave this session with tips, scripts, and more confidence than ever when having these essential conversations. BIO: In 2010, Ms. Hudson began working as the personal assistant to Dr. Ray Foxworth, president and founder of ChiroHealthUSA. She very quickly learned her passion for chiropractic. With her constant desire to learn more and to contribute, she developed what is now one of the largest webinar series within the profession. In 2016, Ms. Hudson took on the additional role of Administrator of the ChiroHealthUSA Foxworth Family Scholarship program. Shei has presented for a number of chiropractic state associations, ChiroCode Institute, ChiroHealthUSA, ChiroTouch Software,

and more. She has written numerous articles on billing, collections, staff training and compliance and has received professional certification as a Certi-fied Professional Com-pliance Officer.

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The Homestead ResortHot Springs, VA

Experience the Southern hospitality and elegant charm that have made The Homestead Resort a premier destination for 23 U.S. presidents. Located

across more than 2,000 acres of scenic Virginia landscape, the resort provides timeless comforts and access to an exciting array of activities.Two major hot springs flow onto the property, featuring a full-service spa and unique Spa Garden and offering you the opportunity to take in the mineral waters just as President Thomas Jefferson did in 1818. A two-acre water park, fueled by crystal-clear springs, features water slides, a lazy river and a water play zone for the kids, along with a whirlpool and private cabanas with exclusive services. With the mountains and valleys bursting with activities such as golf, horseback riding, paintballing, zip lining and hiking, an adventure is always within easy reach. Following a day of learning or fun, fill up at one of the thoughtfully designed restaurants or join your colleagues in the cozy lobby bar.Each guest room is beautifully appointed with down pillows and featherbeds. Hand-selected artwork showcases the region’s history. Today’s amenities like Wi-Fi and flat-screen TVs enhance authentic details such as sun porches and working fireplaces.Arrive early or stay an extra day to take advantage of this special destination at phenomenal rates. For reservations at a special standard room rate, call 1-800-838-1766 by April 25th and specify the “Unified Virginia Chiropractic Association” block. To register online, go to “https://www.omnihotels.com/hotels/homestead-virginia/meetings/unified-virginia-chiropractic-association-spring-convention.” We have a limited # of standard rooms available at $172++, single or double. When those are gone, the rate will go to $185++. Special rates on beautiful suites, too!

AFTER APRIL 25,reservations are on a space and rate available basis.

*** However, rooms at these special rates are very likely to sell out well before then, so call now!!! ***

Thank You, Early Sponsors8 Weeks to Wellness

Anabolic LaboratoriesChiroHealthUSA

The Family PracticeFoot Levelers

Gold Star Medical Business Services

Laser Biotech InternationalLife University

NCMICThe Running Clinic

Page 6

Silent AuctionThe UVCA Public Relations Committee’s popular silent auction returns to add fun and raise money supporting initiatives to spread chiropractic’s vital message. Bid on everything from chiropractic equipment and office supplies to designer jewelry, sports memorabilia and hotel stays. Can you contribute an item for the auction? Contact Dr. Swift, Auction Chair, at [email protected].

Attendee DiscountsUVCA convention attendees and guests enjoy discounted rates at the resort’s championship golf courses, the Homestead Spa (Thursday and Friday), and the fine dining breakfast buffet.

Restaurant AlternativesThe hotel offers several dining outlets, including fine dining, casual fare, and a market/coffee shop. Additional eateries, including several with very affordable pricing, are just a stroll or short drive away.

ExhibitsFind out what’s new in the marketplace! Visit with exhibitors representing a wide range of products and services.

Silen

t Auc

tion

Chiropractic PRfor

2018

Golf OutingIf there is sufficient demand, a group golf event will be organized for Friday morning for UVCA attendees, family and friends. However, regardless, play either course at dis-counted attendee rates!

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Spring Convention 2018May 18-20, Hot Springs, VA

(Please use a separate form for each registrant)

Your Name:_______________________________________________________________________

If Staff, Your DC’s Name:____________________________________________________________

Practice Name:____________________________________________________________________

Street:____________________________________________________________ Ste:___________

City:___________________________________________ State:________ Zip:_________________

Phone:_________________________________ Fax:______________________________________

E-mail for Confirmation:______________________________________________________________

CHECK: __Unified VCA Member DC __PREMIER Member DC* __Non-Member DC __Staff of Member DC __Staff of PREMIER DC* __Staff of Non-Member DC

Early Regular Late By 3/15 3/16-4/16 After 4/16__ Unified VCA Member DC $357 $407 $457__ Non-Member DC $557 $607 $657__ 1st CA from UVCA Member Office $199 $249 $299__ Addl CA from Member Office (each) $179 $229 $279__ 1st CA from Non-Member Office $239 $289 $339__ Addl CA from Non-Member Office (each) $219 $269 $319PREMIER MEMBERS

What’s a Premier Member? Find out at www.virginiachiropractic.org (Membership tab)

__Unified VCA Premier Member DC FREE $50 $100__1st CA from Premier Member Office FREE $50 $100__ Addl CA from Premier Member Office (each) $159 $209 $259

Payment: $____________ Registration Fee from Above

__Check, Payable to VCA OR Charge: __Visa __MC __Discover __AMEX

Card #:__________________________________________________________________________

Expiration Date:__________________________ 3-4 Digit Authorization #:_____________________

Complete Billing Address (if different from above): ________________________________________

________________________________________________________________________________

Name on Card:____________________________________________________________________

Signature:___________________________________________________ Date:________________

Cancellations: If written notification of cancellation is received at least 72 hours prior to convention start, payment will be refunded, less a $50 pro-cessing fee. No refunds or credits issued within 72 hours of program.

• REGISTERONLINEatwww.virginiachiropractic.org

• FAX completed registration form to 540-932-3101

• MAIL to VCA Spring Convention, POB 15, Afton, VA 22920• Questions? CALL 540-932-3100

DC & CA Registration Form

*PREMIERMember DCs& 1 CA each

attend forFREE, plus add’l CAs

enjoy add’l discounts

PRE-REGISTRA-

TIONREQUIRED

Inquire about a Friday morning Gorge hike, FREE history tour, spa discounts or group golf outing!

OPTIONAL: I’ll donate the following for the Silent Auction to support Chiropractic PR!

____________________________________

____________________________________

____________________________________

__________ Est’d Retail Value $___________