Kerry Confirm Room Location

SAM STUDY HALL REGISTRATION FORM TOPIC: Asthma

Saturday, December 13, 2014, 8:30 am – 12:30 pm

The Historic Overlook House 3839 N. Melrose Drive, Portland, OR

What to expect: Josh Reagan, MD will lead the group through the written portion of the Self Assessment Module. Josh has access to all the background research materials used for this SAM, in case there is any disagreement about the correct answers. At the end of the test, everyone will have passed.

At this point, you will need to have a laptop or iPad and log into the ABFM website. If you have not already pre-paid the ABFM for your Maintenance of Certification, you will need to pay them. If you would like to pre-pay, please visit https://www.theabfm.org/. If you don’t have access to a laptop computer, please let me know. We may be able to borrow one for you.

Josh will be available for anyone who needs help with the Clinical Assessment part of the SAM. He has taken many of these Assessments and knows how they work.

Please complete this registration form and return it to the OAFP office, [email protected], 1717 NE 42nd Ave. Suite 2103., Portland, OR 97213, or fax 503-528-0996.

Best phone number for last minute instructions/changes:______

AAFP member ID # (if you have it handy. Otherwise we can look it up):______

Registration fee $50

I will pay at the door ______

I have enclosed a check (payable to the OAFP) ______Mailing address: 1717 NE 42nd Ave., Suite 2103., Portland, OR 97213

Please bill my credit card: ______Visa or Mastercard only

Credit card number:______

Expiration date:______