2019 IPC Psoriasis Master Class | Vienna - Registration & Application

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* 1. Please provide your name and contact information.

First Name: *

Last Name: *

Place of work (hospital, university, etc.): *

Credentials/professional qualifications (MD, PhD, other):

City/Town: *

Country:

Email Address:

Phone Number:

The following information is being requested by the faculty to better prepare a customized program agenda.

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* 2. How many years have you been treating psoriasis?

0-5 years

6-10 years

More than 10 years

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* 3. How many psoriasis patients do you see per month?

Under 25

25-50

51-100

More than 100

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* 4. What percentage of your psoriasis patients are in the following categories?

	% of patients seen per month
Mild:	Mild: % of patients seen per month menu
Moderate/Severe:	Moderate/Severe: % of patients seen per month menu

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* 5. Are you treating patients with complex psoriasis ( treatment resistant, treatment complications and/or comorbid psoriasis):

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* 6. Are you screening and diagnosing comorbidities?

Always

Usually

Sometimes

Rarely

Never

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* 7. Are you treating comorbidities

Yes

No, but I refer patients with comorbidities to other care providers for treatment

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* 8. Will you be able to attend both days of the course?

Yes

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* 9. Will you attend the optional welcome dinner, Thursday Nov. 14?

Yes

Not sure

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* 10. How do you envision this course impacting your ability to care for psoriasis patients? What do you hope to learn from this course?

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* 11. Please read the statement below and mark the check box to accept.

I hereby give consent to IPC to store my personal information namely, my name, city, email id, credentials, and clinical experience in its records. I understand that this information will only be used for me to receive materials related to the psoriasis master class and for IPC to develop the content of this course.