Melvin L. Cohen, MD 36th Annual Pediatric Update 2013 Feb. 25 through 28, 2013 Ritz-Carlton, Phoenix, Arizona ABOUT PHOENIX CHILDREN’S HOSPITAL Phoenix Children’s Hospital, ranked in U.S. News & HOSTED BY PHOENIX CHILDREN’S HOSPITAL for the past 36 World Report’s Best Children’s years, Pediatric Update offers physicians from across the country Hospitals, is Arizona’s only the opportunity to learn the latest evidence-based practices in licensed children’s hospital, pediatric medicine. This event welcomes hundreds of pediatricians providing world-class inpatient, from throughout the United States who recognize and value this outpatient, trauma, emergency, opportunity for continuing medical education and urgent care to children COURSE OBJECTIVE Pediatric Update 2013 features nationally prominent faculty, presenting topics that highlight the most recent advances and current issues in pediatrics. The program is designed for practicing pediatricians, other primary care physicians and pediatric nurse practitioners to increase their knowledge in the following subspecialty areas: Cardiology, Dermatology, Developmental Pediatrics, Endocrinology, General Pediatrics, Gastroenterology, Infectious Disease, Information Technology, Integrative Medicine, Otolaryngology, Plastic Surgery, Psychiatry, and Surgery/Trauma. This course will combine lectures and workshops with question and answer sessions to allow the opportunity for interaction with faculty members. and families in Arizona and throughout the Southwest. As one of the largest children’s hospitals in the country with 465 licensed beds, Phoenix Children’s provides care across nearly 50 pediatric specialties. The Hospital is poised for continued growth in quality patient care, research and SETTING The Ritz-Carlton offers a luxury experience in a relaxed, urban surrounding. 325 days of sunshine each year create ideal conditions to enjoy the area attractions. Located about 8 miles from Sky Harbor Airport (a 15 to 20 minute drive), the hotel is near more than 60 upscale shopping and dining venues, all a convenient stroll away. A limited number of guest rooms are being held at the Ritz-Carlton for a reduced rate of $219 per night, plus an occupancy tax of 13.27%. Please plan to reserve your guest room well in advance. To learn more about The Ritz-Carlton, Phoenix, visit their website at www.ritzcarlton. com/phoenix. medical education. For more information about the Hospital, visit www.phoenixchildrens.com. COURSE CREDIT Phoenix Children’s Hospital is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide Continuing Medical Education for physicians. Phoenix Children’s Hospital designates this live activity for a maximum of 17.3 AMA PRA Category 1 Credits TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. MAINTENANCE of CERTIFICATION (MOC) PART TWO An application for MOC Part Two credits has been submitted to the American Board of Pediatrics (ABP). Further details will follow. Faculty Mitchell Cohen, MD, FACC, FHRS Medical Staff Section Chief, Pediatric Cardiology Director of Pediatric Electrophysiology and Pacing Phoenix Children’s Hospital Arizona Pediatric Cardiology Consultants Phoenix, Arizona Clinical Associate Professor of Pediatrics University of Arizona School of Medicine Tucson, Arizona Paul Croarkin, DO Senior Associate Consultant Department of Psychiatry and Psychology Mayo Clinic Assistant Professor of Psychiatry Mayo Clinic College of Medicine Rochester, Minnesota Ronald Hansen, MD Division Chief, Dermatology Phoenix Children’s Hospital Phoenix, Arizona Professor of Medicine, Pediatrics and Dermatology University of Arizona Health Science Center Tucson, Arizona Mayo Clinic, Consultant, Dermatology Scottsdale, Arizona Marcia Hogeling, MD Pediatric Dermatologist Department of Dermatology Phoenix Children’s Hospital Phoenix, Arizona Tieraona Low Dog, MD Fellowship Director Arizona Center for Integrative Medicine Clinical Assistant Professor of Medicine University of Arizona Health Sciences Tucson, Arizona Hilary McClafferty, MD, FAAP Founder of the Center for Women and Children’s Integrative Medicine Chapel Hill, North Carolina AAP Section on Complementary and Integrative Medicine Executive Committee Member Assistant Fellowship Director Arizona Center for Integrative Medicine University of Arizona College of Medicine Tucson, Arizona Don McClellan, MD Pediatric Endocrinologist Division Chief, Endocrinology Phoenix Children’s Hospital Phoenix, Arizona Tamir Miloh, MD Academic Division Chief Pediatric Gastroenterology Director, Liver Transplantation Program Phoenix Children’s Hospital Phoenix, Arizona Associate Professor of Pediatrics Mayo Clinic College of Medicine Associate Professor of Pediatrics University of Arizona College of Medicine Tucson, Arizona Bruce Morgenstern, MD Division Chief, Nephrology Medical Director, Continuing Medical Education Phoenix Children’s Hospital Phoenix, Arizona Professor of Pediatrics University of Arizona College of Medicine Tucson, Arizona Associate Professor of Pediatrics Mayo Clinic College of Medicine David Notrica, MD, FACS, FAAP Trauma Medical Director Phoenix Children’s Hospital Phoenix, Arizona Pediatric Surgeon, Pediatric Surgeons of Phoenix Phoenix, Arizona Clinical Assistant Professor of Surgery University of Arizona College of Medicine Tucson, Arizona Stephen Pophal, MD, FACC Division Chief, Pediatric Cardiology Phoenix Children’s Medical Group Phoenix Children’s Hospital Phoenix, Arizona Harper Price, MD, FAAD, FAAP Fellowship Director and Associate Chief, Department of Dermatology Phoenix Children’s Hospital Phoenix, Arizona Instructor in Dermatology Mayo Clinic College of Medicine William Raszka, MD Pediatric Infectious Disease Specialist, Fletcher Allen Professor, University of Vermont College of Medicine Vermont Children’s Hospital at Fletcher Allen Children’s Specialty Center Burlington, Vermont Scott Schraff, MD Division Chief, Pediatric Otolaryngology Phoenix Children’s Hospital Phoenix, Arizona Adjunct Assistant Professor, Department of Otolaryngology Mayo Clinic College of Medicine Steven Shukan, MD General Pediatrician Summit Camp Health Center Director Hope for Haiti Physician Naples, Florida Davinder Singh, MD Assistant Professor of Plastic Surgery Mayo School of Medicine Scottsdale, Arizona Chief, Division of Plastic Surgery Phoenix Children’s Hospital Attending Surgeon, Barrow Children’s Cleft and Craniofacial Center Phoenix, Arizona Vinay Vaidya, MD Vice President and Chief Medical Information Officer Phoenix Children’s Hospital Phoenix, Arizona Robert Voigt, MD Professor of Pediatrics Baylor College of Medicine Developmental Pediatrician Meyer Center for Developmental Pediatrics Texas Children’s Clinical Care Center Houston, Texas Jeffrey Weiss, MD General Pediatrician and Hospitalist Phoenix Children’s Hospital Phoenix, Arizona AAP Committee on Injury, Violence and Poison Prevention Clinical Professor of Pediatrics University of Arizona College of Medicine Tucson, Arizona Monday, February 25 7 - 8 a.m. Breakfast Buffet 7:30 a.m. Breakfast Workshops Don McClellan, MD & Tamir Miloh, MD Pediatric Obesity: Sweet Kids/Fat Livers (repeat on Tuesday) As a result of attending this presentation, participants should be able to: • identify key diagnostic features of type 2 diabetes in children and adolescents • recognize the co-morbidities of obesity in children and adolescents • recognize the prevalence and risk factors for non alcoholic fatty liver in children (NAFLD 2) • discuss the differential diagnosis, workup and management of children with NAFLD Hilary McClafferty, MD, FAAP Introduction to Mind-Body Medicine: Tools for Clinical Practice As a result of attending this presentation, participants should be able to: • discuss three evidence-based mindbody medicine techniques applicable in pediatric practice • recognize clinical settings where the use of mind-body medicine techniques can be safely applied Ronald Hansen, MD & Marcia Hogeling, MD Hemangiomas and Vascular Malformations As a result of attending this presentation, participants should be able to: • review propranolol for the treatment of infantile hemangioma • recognize the most common types of vascular malformations • discuss multidisciplinary approach to managing vascular malformations 8:30 a.m. Bruce Morgenstern, MD Welcome and Introduction 8:40 a.m. William Raszka, MD Going With the Flow: Diagnosis, Treatment and Prevention of Urinary Tract Infections (UTI) In Young Children As a result of attending this presentation, participants should be able to: • review risk categories for UTI • describe criteria for the diagnosis of UTI • compare and contrast current recommendations with past recommendations • identify children in whom imaging studies are indicated 9:20 a.m. Hilary McClafferty, MD, FAAP An Integrative Approach to ADHD As a result of attending this presentation, participants should be able to: • describe the elements of a comprehensive integrative medicine approach to ADHD • prioritize an integrative medicine approach to selected patients with ADHD in a case-based format 10 a.m. Break 10:20 a.m. Scott Schraff, MD Dysphagia: Why a Multidisciplinary Approach is Needed As a result of attending this presentation, participants should be able to: • outline the causes of dysphagia and discuss the workup of dysphagia in children • use a treatment algorithm for dysphagia and explain why a multidisciplinary approach is needed 11 a.m. Harper Price, MD, FAAD, FAAP Acne, New Concepts and Controversies As a result of attending this presentation, participants should be able to: • review new literature and trends for acne therapy in the pediatric population 11:40 a.m. William Raszka, MD Getting To the Point: Vaccine Issues in 2012 As a result of attending this presentation, participants should be able to: • review reasons for vaccine deferment • describe the epidemiology of vaccine preventable diseases • compare and contrast vaccine schedules • discuss new indications or changes in vaccine schedules Tuesday, February 26 7 - 8 a.m. Breakfast Buffet 7:30 a.m. Breakfast Workshops Vinay Vaidya, MD Electronic Health Records: How Can We Improve Safety and Efficiency? As a result of attending this presentation, participants should be able to: • explain the role of electronic health records in clinical decision support • recognize how electronic health records can enhance patient safety Tieraona Low Dog, MD The Role of Herbal Medicine in Pediatrics As a result of attending this presentation, participants should be able to: • describe the use of herbal products in the United States • discuss the safety and benefit for herbal remedies commonly used in the pediatric population • describe the key components of the dietary supplement facts label as it pertains to herbs and herbal extracts • identify authoritative resources in obtaining unbiased information for assessing safety and effectiveness of herbal remedies Don McClellan, MD & Tamir Miloh, MD Pediatric Obesity: Sweet Kids/Fat Livers (repeat from Monday) As a result of attending this presentation, participants should be able to: • identify key diagnostic features of type 2 diabetes in children and adolescents • recognize the co-morbidities of obesity in children and adolescents • recognize the prevalence and risk factors for non alcoholic fatty liver in children (NAFLD 2) • discuss the differential diagnosis, workup and management of children with NAFLD 8:40 a.m. William Raszka, MD Flim, Flam and Phlegm: Diagnosis and Treatment of Community Acquired Pneumonia (CAP) in Healthy Children As a result of attending this presentation, participants should be able to: • review the indications for diagnostic testing in patients with signs and symptoms of LRTI • describe therapeutic strategies for children with CAP • discuss management of complicated pneumonias 9:20 a.m. Hilary McClafferty, MD, FAAP Pediatric Integrative Medicine: Looking Forward As a result of attending this presentation, participants should be able to: • define integrative medicine • describe the evolution of the field of pediatric integrative medicine in the United States • identify clinical settings in which evidence-based pediatric integrative medicine is being widely used 10 a.m. Break 10:20 a.m. Scott Schraff, MD Pediatric Head and Neck Masses: When to Worry About Lumps As a result of attending this presentation, participants should be able to: • discuss the clinical signs and symptoms of neck masses in the pediatric patient • discuss the workup of head and neck masses in children • use a treatment algorithm for neck masses and give guidance on when to refer the patient to a specialist 11 a.m. Jeffrey Weiss, MD Talking to Families about Preventing Injuries As a result of attending this presentation, participants should be able to: • counsel families about drowning prevention (swim lessons, pool fences) • counsel families about high risk teen driving (night driving, teen passengers, distractions, seatbelts) • apply the Social Learning Theory model in counseling aimed at true behavior change 11:40 a.m. William Raszka, MD What Would Jack Do? Emerging Infectious Disease Threats As a result of attending this presentation, participants should be able to: • describe the epidemiology of new (in the US) infections • review the epidemiology, diagnosis and treatment of infections associated with Wednesday, February 27 7 - 8 a.m. Breakfast Buffet 7:30 a.m. Breakfast Workshops Paul Croarkin, DO Case Presentations of Pediatric Mood Disorders As a result of attending this presentation, participants should be able to: • discuss screening, identification and management of depressive disorders and bipolar disorder in children and adolescents (this will be accomplished with interactive discussion and video vignettes) • demonstrate an increased awareness, comfort and ability in screening and managing suicidality in a primary setting Robert Voigt, MD Pediatric Diagnosis and Management of Autism Spectrum Disorders As a result of attending this presentation, participants should be able to: • recognize autism spectrum disorders within the spectrum and continuum of developmental-behavioral disorders, not just a simple checklist of behaviors • describe the developmental and behavioral profiles of children with autism and Asperger syndrome • define “pervasive developmental disorder, not otherwise specified” • discuss the proposed changes in autism diagnosis in the upcoming DSM-V • recommend evidence-based behavioral, therapeutic, special educational and medical interventions for children with autism spectrum disorders • apply a cost-effective, yet comprehensive approach to laboratory workup of children with autism spectrum disorders Mitchell Cohen, MD, FACC, FHRS ECG Reading and When to Really Worry As a result of attending this presentation, participants should be able to: • recognize abnormal EKGs which may identify children at risk for sudden cardiac death 8:40 a.m. David Notrica, MD, FACS, FAAP Chest Injury for the Urgent Care Physician As a result of attending this presentation, participants should be able to: • review the physiology of chest injury and pneumothorax types • discuss which chest injuries can be safely discharged • review changes in clavicle fracture management 9:20 a.m. Paul Croarkin, DO Managing Pediatric Mood Disorders in a Primary Care Setting As a result of attending this presentation, participants should be able to: • demonstrate increased knowledge regarding the epidemiology, phenomenology and treatments of depressive disorders and bipolar disorders • demonstrate increased competency in basic management strategies (including psychosocial interventions, pharmacotherapy and referrals) for pediatric mood disorders 10 a.m. Break 10:20 a.m. Robert Voigt, MD Screens Have Holes: Pediatric Neurodevelopmental Assessment As a result of attending this presentation, participants should be able to: • define and differentiate developmental screening, surveillance and evaluation • describe the processes that underlie problems in development: developmental delay, dissociation and deviation • identify patterns of developmental delay static, acute and progressive – understand how these patterns affect medical work-up and recommendations for therapy • perform clinical pediatric neurodevelopmental assessments utilizing a developmental history and neurodevelopmental examination 11 a.m. David Notrica, MD, FACS, FAAP Surgical Management of Fecal Incontinence and Intractable Constipation As a result of attending this presentation, participants should be able to: • explain the etiologies and workup of fecal incontinence • review the child’s right to “social continence” • recognize options for failure medical management of constipation 11:40 a.m. Mitchell Cohen, MD, FACC, FHRS A Practical Approach to Screening for Sudden Cardiac Death As a result of attending this presentation, participants should be able to: • recognize the cardiovascular causes of sudden cardiac death • identify limitations of current sports screening forms • explain subtle findings that support a patient at risk for cardiovascular arrhythmias Thursday, February 28 7 - 8 a.m. Breakfast Buffet 7:30 a.m. Breakfast Workshops Steven Shukan, MD Initial Medical Response – Haiti, January 2010 “Flying by the Seat of One’s Pants” As a result of attending this presentation, participants should be able to: • express the devastation encountered by the medical team upon arrival in Haiti • describe what was required of the first medical personnel on the scene and recognize the resilience of the Haitian people • express pride in being American • describe a young Haitian boy’s “lesson to be learned” Robert Voigt, MD Cases in Developmental-Behavioral Pediatrics As a result of attending this presentation, participants should be able to: • adopt a clinical pediatric developmental assessment process that focuses on developmental history and neurodevelopmental examination rather than screening and checklists • diagnose common developmentalbehavioral conditions (cerebral palsy, intellectual disability, ADHD, autism spectrum disorders) using this process Stephen Pophal, MD, FACC Common Congenital Heart Defects in Children: How to Diagnose Them and When to Refer for Nonsurgical Intervention As a result of attending this presentation, participants should be able to: • discuss the most common heart lesions in children that require nonsurgical intervention and when they are repaired 8:40 a.m. Davinder Singh, MD Craniofacial Anomalies: Management in the Newborn Period As a result of attending this presentation, participants should be able to: • describe team effort in caring for newborns with craniofacial anomalies • recall the timeline for staged reconstruction of craniofacial anomalies 9:20 a.m. Stephen Pophal, MD, FACC New Approaches to Nonsurgical Interventions in Congenital Heart Disease (CHD) As a result of attending this presentation, participants should be able to: • identify the most common congenital heart lesions that are repaired non surgically and gain a basic understanding of how they are repaired • describe the routine follow-up after nonsurgical/catheter based repairs of CHD 10 a.m. Break 10:20 a.m. Robert Voigt, MD Beyond Checklists: Making DevelopmentalBehavioral Diagnoses As a result of attending this presentation, participants should be able to: • discuss the basic pediatric neurodevelopmental principles that underlie the spectrum and continuum of developmental-behavioral disorders • describe the spectrum of developmental disabilities from mild to severe within each stream (motor, cognitive, behavior) of development • describe the continuum of developmental disabilities across developmental streams and the importance of identifying associated developmental and/or behavioral co-morbidities • formulate comprehensive developmental/ behavioral diagnoses within the spectrum and continuum of developmental behavioral disorders 11 a.m. Davinder Singh, MD Acute Management and Long Term Growth Consequences As a result of attending this presentation, participants should be able to: • review indications and timing of surgical intervention for pediatric facial fractures • recognize the effect of trauma on facial growth 11:40 a.m. Paul Croarkin, DO Identification and Management of Suicidality in Children and Adolescents As a result of attending this presentation, participants should be able to: • recall the epidemiology, identification and risk factors associated with suicidality • demonstrate increased competency in the screening and management of suicidality in a primary care setting Evening Reception & Hospitality Suite Join us Tuesday, February 26th, from 6 to 9:00pm at The Ritz-Carlton. Relax poolside and enjoy the entertainment! A delightful selection of hors d’oeuvres, wine and cocktails will be served. HOSPITALITY SUITE Spouses and other guests are invited to visit the Hospitality Suite on Monday, Tuesday and Wednesday from 8 to 11:30 a.m. Continental breakfast will be served. PARKING Daytime parking at the Ritz-Carlton is complementary. Overnight parking is $29.00 per night (we recommend overnight guests use a taxi service rather than car rental). Overflow parking is available in the Esplanade parking garage at $14.00 per day. The Biltmore parking lot, located directly across from the Ritz-Carlton, may also be used for overflow parking at no charge. The Ritz-Carlton valet service will be available to direct you and provide options for parking if needed. Registration SEATING IS LIMITED AND SUBJECT TO AVAILABILITY- EARLY REGISTRATION IS ENCOURAGED The fee to attend Pediatric Update is $575 for practicing The fee to attend Pediatric Update is $575 for practicing physicians and $450 for retired physicians, nurses, residents and other allied health professionals. Those who register for the course and reserve a room through the Phoenix Children’s Hospital-Pediatric Update guest room block at Ritz-Carlton, prior to 12/31/2012, will receive a course registration discount of $50. The registration fee includes tuition, breakfast each morning, refreshments during the meeting and two tickets for the Reception on Tuesday evening. Presentations/Syllabus material will be available on the Phoenix Children’s Hospital Website at www. phoenixchildrens.com – thumb drives will be distributed to each registrant upon check in at the conference registration desk. If you wish to purchase a printed syllabus for the main course, one will be provided upon check in for a $40 fee to cover the cost of printing. Please indicate that you wish to purchase a printed copy of the syllabus on your course registration form. If you wish to bring additional guests to the Reception, please include $60 in your tuition for each additional person. If your spouse or guest plans to attend the Breakfast Buffet for registered participants, please include an additional $60 in your tuition fee for each spouse or guest. The registration and information desk will be open from 5 to 7 PM on Sunday, February 24 (for those who wish to check in early) and daily throughout the conference. The full fee is payable upon registration. Please make checks payable to: Pediatric Update 2013 (ALL FEES IN US CURRENCY). In case of emergency, cancellation of your registration will be accepted up to two weeks prior to the meeting date, with a refund of your registration fees, less a $50 processing charge. Registration fees will not be refunded for cancellations received within two weeks of the conference. Course registrants will have the opportunity to participate in workshops during breakfast. Upon receipt of your registration a workshop form will be sent to you. Please make your workshop selections and return by FAX: (602) 933-0806 at your earliest convenience. Registration is also available online at the following address: www.phoenixchildrens.com/calendar-of-events For further information and assistance with special requests, please contact: JoAnn Cunningham, Medical Education Phoenix Children’s Hospital 1919 East Thomas Road, Phoenix, Arizona 85016 (602) 933-0766 or 933-0761 - Fax: (602) 933-0806 E-mail: [email protected] Course Registration Form You can now register via your smartphone-just simply Clip and send course registration form directly to: follow the steps below: (Make Copy for Additional Attendees) 1. Download QR code app QR code Phoenix Children’s Hospital -Medical Education Department Attention: JoAnn Cunningham 2. Scan code 1919 E. Thomas Rd., Administration Building to the right Phoenix, AZ 85016 3. Register FAX (602) 933-0806 Registration is also available online: www.phoenixchildrens.com/pediatricupdate Print Name ________________________________________________________________ Degree _______________ Print Address______________________________________________________________________________________ Print City ______________________________________________________ State ____________ Zip _____________ Business Phone (____)_____________________________ Home Phone (____) ________________________________ Fax (____)_______________________________________ Email Address ____________________________________ Do you plan to attend the reception? Yes No Will your spouse/guest be attending the reception? Yes No One Reception ticket will be provided for each registrant and the registrant’s spouse or a guest. Additional reception tickets will be available for purchase ($60 each) at the conference registration desk. Will your spouse/guest be attending the breakfast buffet for registered participants? Yes No Breakfast Buffet tickets will be provided for each registrant. Additional tickets will be available for purchase ($60 each) at the conference registration desk (price includes breakfast buffet Monday through Thursday). Pediatric Update 2013 Tuition Physicians registering for the course and reserving a room through the Phoenix Children’s Hospital-Pediatric Update guest room block at Ritz-Carlton, prior to 12/31/2012$525__________ Physicians registering after 12/31/2012$575__________ Retired Physicians, Residents, Fellows, Nurses/Allied Health $450__________ I wish to bring _____ additional guest/s to the reception on Tuesday $60 per person__________ My spouse/guest/s plan(s) to attend the breakfast buffet for registered participants $60 per person __________ (Price includes breakfast buffet Monday through Thursday) I wish to purchase a printed copy of the syllabus $40 __________ PAYMENT MAY BE MADE BY CHECK or CREDIT CARD PLEASE MAKE CHECK PAYABLE TO: Pediatric Update 2013 (ALL FEES in US CURRENCY) PLEASE CHARGE MY: American Express MasterCard Visa Credit Card Number____________________________________________________ Expiration Date _______________________ Card Holder Signature __________________________________________________ Print Name as Shown on Card ___________________________________________ Total __________ Advanced Hotel Reservation Form THE RITZ-CARLTON, PHOENIX • 2401 East Camelback Road • Phoenix, AZ 85016 • Phone: (602) 648-0700 To Make a Reservation by Phone: (800) 241-3333 To Fax Your Reservation Form: (602) 553-0685 Attention: Joseph Vita in Group Reservations Online go to: ritzcarlton.com/phoenix Email: [email protected] Reference Group Code: PCHPCHA Official Dates for Guest Room Reservations: Saturday, February 23 through Saturday, March 2, 2013. Reservations must be received by: Thursday, January 24, 2013. Airport Transportation: Phoenix Sky Harbor Airport Taxi service or public shuttle is available at each terminal. The Ritz-Carlton is located about 8 miles from Sky Harbor Airport (a 15 to 20 minute drive). Room rates are subject to 13.27% occupancy tax. All reservation requests must be accompanied by a one-night non-refundable deposit (check, money order or credit card) in order for the reservation to be processed and confirmed. Deposits will be refunded for rooms cancelled more than 72 hours prior to arrival. The Ritz-Carlton, Phoenix ATTENTION: Joseph Vita Group Reservations I plan to attend The Melvin L. Cohen, MD Pediatric Update 2013 Sponsored by Phoenix Children’s Hospital Group room rates (standard accommodations) Please check one: $219.00 Double $219.00 Double/Double Check-in: 3 p.m. $219.00 King Check-out: 12 p.m. Name _____________________________________________________________________________________________ Address____________________________________________________________________________________________ City _________________________________________________________State ____________ Zip__________________ Email_______________________________________________________________________________________________ Business Phone (____)___________________________________ Home Phone (____) ____________________________ # Guests _____# Adults _____# Children _____ Requests _________________________________________________ Arrival Date __________________ Time ________________Departure Date ________________Time ______________ Credit Card Name __________________________________________________________________________________ Credit Card Number_____________________________________________Expiration Date_______________________ I authorize Ritz-Carlton to charge my account for one night’s room and tax or please find my check/money order enclosed. Card Holder Signature__________________________________________________Date_________________________ Print Name as Shown on Card ________________________________________________________________________ 12-0259
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