PHYSICIAN CEO Online Application

PHYSICIAN CEO PROGRAM
WHO SHOULD ATTEND
FACULTY
TESTIMONIALS
FAQ’s
APPLY
CONTACT
GALLERY
PHYSICIAN CEO 2023 PARTICIPANT PAGE

PHYSICIAN CEO PROGRAM
WHO SHOULD ATTEND
FACULTY
TESTIMONIALS
FAQ’s
APPLY
CONTACT
GALLERY
PHYSICIAN CEO 2023 PARTICIPANT PAGE

PHYSICIAN CEO^® Online ApplicationSurgiVision^® Consultants Inc. is proud to offer the PHYSICIAN CEO^® program,developed in collaboration with the Kellogg School of Management at Northwestern University.

PHYSICIAN CEO Application

FULL NAME*
First Middle Last
PRACTICE NAME*
PRACTICE ADDRESS*
Street Address City State / Province / Region ZIP / Postal Code Country

All mail regarding the PHYSICIAN CEO program will be sent to the address provided above.
EMAIL*
Enter Email Confirm Email

The email address provided here will be used for the PHYSICIAN CEO Program course materials, faculty correspondence and administrative information transfer. If you have multiple email addresses, please provide the email address you check most frequently, can accept attachments, embedded links and/or HTML formatting. Please DO NOT provide and email address that accepts “Plain Text” only.
OFFICE TELEPHONE*
CELLULAR PHONE NUMBER*

We request your cell phone number to be used only in the event of an emergency or if we must make contact with you should you not be at your practice location.
WEBSITE*
DEGREE/CREDENTIALS*
- MD
- DO
- MBBS
- MD, PhD
- Other
BOARD CERTIFICATION*
- Board-Certified
- Board-Eligible
- Neither
- Other
CERTIFYING BOARD*

Please provide the name of the board which awarded your certification(s). i.e. ABO or American Board of Ophthalmology.
BOARD CERTIFICATION – ELIGIBLE*

Please provide the name of the board which WILL award your certification(s). i.e. ABO or American Board of Ophthalmology AND include the year you plan to take your boards.
BOARD CERTIFICATION – NEITHER*

Please describe your selection of “Neither” for “Board Certification”.
BOARD CERTIFICATION – OTHER*

Please describe your selection of “Other” for “Board Certification”
DATE OF BIRTH*
Month
Day
Year
GENDER*
- Male
- Female
MEDICAL SCHOOL GRADUATION YEAR*

Please enter a four digit year i.e. 2005
OTHER DEGREE/CREDENTIALS*
FIELD OF MEDICAL SPECIALITY*
- Anesthesiology
- Cardiology
- Concierge Medicine
- Dermatology
- Family Medicine
- Fertility
- General Surgery
- Oncology
- Ophthalmology
- Orthopedics
- Pain Medicine
- Pediatrics
- Plastic & Reconstructive
- Sports Medicine
- Vascular Medicine
- Other
FIELD OF MEDICAL SPECIALTY – OTHER*

Please describe your selection of “Other” for “Field of Medical Specialty
HOW DID YOU COME TO LEARN ABOUT PHYSICIAN CEO? (Check all that apply)*
- AAD – American Academy of Dermatology
- AAO – American Academy of Ophthalmology
- AECOS – American & European Society Ophthalmic Surgeons
- AID – Association of Independent Doctors
- ALPHAEON / Strathspey Crown
- ASCRS – American Society Cataract & Refractive Surgeons
- ASPS – American Society of Plastic Surgeons
- DOTB – Docs Outside the Box
- ESCRS – European Society Cataract & Refractive Surgeons
- Facebook, LinkedIn, Social Media
- Friend / Colleague
- Industry Meeting
- Kellogg School of Management / Northwestern University
- MillennialEYE / MELive
- PHYSICIAN CEO Alumni / Attendee
- Physician Leadership Career Network
- RSA – Refractive Surgery Alliance Society
- Web Search
- Word of Mouth
- Other
PERCENT OF YOUR PRACTICE DEVOTED TO PATIENT-PAY SERVICE*
- None at this time
- < than 25%
- 25% to 50%
- 51% to 75%
- 76% to 99%
- 100%
FORMAL BUSINESS TRAINING*
- None
- Undergraduate Business Degree
- MBA
- Other
PRACTICE POSITION*
- Owner/Partner
- Employee
- Fellow
- Emeritus
- Other
PRACTICE POSITION – OTHER*
FORMAL BUSINESS TRAINING – OTHER*

Please describe your selection of “Other” for “Formal Business Training”
DESCRIBE YOUR GOALS WHILE ATTENDING PHYSICIAN CEO*
DO YOU HAVE ANY DIETARY RESTRICTIONS OR FOOD ALLERGIES?*
- Yes
- No
DO YOU HAVE A DISABILITY REQUIRING SPECIAL ACCOMMODATIONS?*
- Yes
- No
SHIRT SIZE*
- Adult Small
- Adult Medium
- Adult Large
- Adult X-Large
- Adult XX-Large
MY DIETARY RESTRICTIONS/FOOD ALLERGIES ARE…*
MY SPECIAL ACCOMMODATION REQUIREMENTS ARE…*
THE PHYSICIAN CEO 2023 PROGRAM DATES

Program Fee Includes:

• Lodging and Accommodations at the James L. Allen Center:

January 28 – February 1, 2023

April 1 – 5, 2023
June 10 – 14, 2023

September 16 – 20, 2023

• Program Tuition

• Text Books and Educational Materials

• Meals, Beverages, Snacks and Social Hours

• Access to the Sports Pavilion Aquatics Center (SPAC) in Evanston
PHYSICIAN CEO 2023 PROGRAM FEE*

$46,745.00 USD – All Inclusive Program Tuition for PHYSICIAN CEO 2023.
Group ID… (Optional)
PHYSICIAN CEO 2023 SPONSORSHIP – FULL TUITION GRANT*

$46,745.00 USD – The PHYSICIAN CEO 2023 SPONSORSHIP for participation in PHYSICIAN CEO 2023 is a special funding opportunity made possible from a grant obtained by SurgiVision Consultants Inc. (SVC). This Sponsorship provides for a one-time, full-tuition grant of $46,745 USD to eligible individuals. It will be applied to the All-Inclusive Program Fee to PHYSICIAN CEO 2023 for the applicant upon acceptance into the program, pending approval by PHYSICIAN CEO Executive Committee. This Grant has no (zero) cash value to applicant, other than to be directly applied by SVC toward the applicant’s tuition for the PHYSICIAN CEO 2023 Program. This award may not be used for any other program, in-part, or in whole and is not transferrable.
RSA MEMBER PREFERRED PRICING – PHYSICIAN CEO 2023 PROGRAM FEE*

$39,733.00 USD – “RSA MEMBER RATE” All Inclusive Program Tuition for PHYSICIAN CEO 2023. RSA Preferred Member Rate is calculated as $46,745 Program Tuition less 15% RSA MEMBER SAVINGS ($7,012) equals $39,733 Program Tuition.
PLCN MEMBER PREFERRED PRICING – PHYSICIAN CEO 2023 PROGRAM FEE*

$42,070.50 USD – “Physician Leadership Career Network Rate” All Inclusive Program Tuition for PHYSICIAN CEO 2023. RSA Preferred Member Rate is calculated as $46,745 Program Tuition less 10% PLCN SAVINGS ($4,674.50) equals $42,070.50 Program Tuition.
KELLOGG PCEO ALUMNI PREFERRED PRICING – PHYSICIAN CEO 2023 PROGRAM FEE*

$32,721.50 USD – “KELLOGG PCEO ALUMNI” Preferred Pricing. The All-Inclusive Program Tuition for a KELLOGG PCEO ALUMNI participation in PHYSICIAN CEO 2023 is calculated as $46,745 Program Tuition less 30% KELLOGG ALUMNI SAVNIGS ($14,023.50) equals $32,721.50 All-Inclusive Program Tuition.
DATALINK PREFERRED PRICING – PHYSICIAN CEO 2023 PROGRAM FEE*

$39,733.00 USD – “DATALINK PREFERRED RATE” All Inclusive Program Tuition for PHYSICIAN CEO 2023. DataLink Preferred Rate is calculated as $46,745 Program Tuition less 15% DATALINK SAVINGS ($7,012) equals $39,733.00 All-Inclusive Program Tuition.
AID PREFERRED PRICING – PHYSICIAN CEO 2023 PROGRAM FEE*

$39,733.00 USD – “AID PREFERRED RATE” All Inclusive Program Tuition for PHYSICIAN CEO 2023. AID Preferred Rate is calculated as $46,745 Program Tuition less 15% AID SAVINGS ($7,012) equals $39,733.00 All-Inclusive Program Tuition.
PCEO ALUMNI GRANT – PREFERRED PRICING for PHYSICIAN CEO 2023 PROGRAM*

$39,245.00 USD – “PCEO ALUMNI GRANT RATE” All Inclusive Program Tuition for PHYSICIAN CEO 2023. PCEO Alumni Grant Rate is calculated as $46,745 Program Tuition less ALUMNI GRANT SAVINGS ($7,500) equals $39,245 Program Tuition.
CHARITABLE ORGANIZATION / PHILANTHROPIC PRICING – PREFERRED PRICING for PHYSICIAN CEO 2023 PROGRAM*

$23,372.50 USD – “Charitable Organization / Philanthropic Endeavors Rate” All Inclusive Program Tuition for PHYSICIAN CEO 2023. Charitable Organization / Philanthropic Endeavors Rate is calculated as $46,745 Program Tuition less 50% Charitable Organization / Philanthropic Endeavors SAVINGS ($23,372.50) equals $23,372.50 Program Tuition.
Total
$0.00
PAYMENT PLAN*

Single (1) Payment – I Elect to Pay the Balance of the Tuition Payment as a Single Payment Due on/by on/by the 30th Day of the Month of my Acceptance Letter Date, Payable by Major Credit Card (using PayPal), Check, Wire Transfer, or Money Order.

Six (6) Equal Payments – I Elect to Pay the Balance of the Tuition Payment as Six Equal Payments, where First Installment Payment is Due on/by the 30th Day of the Month of my Acceptance Letter Date. All Subsequent Installment Payments are Due on/by the 30th Day of Each of the Next Six Months, Payable by Major Credit Card (using PayPal), Check, Wire Transfer, or Money Order.
PAYMENT PLAN*

Single (1) Payment – Should I be Accepted into the PHYSICIAN CEO 2023 Program, I Understand this PHYSICIAN CEO 2023 SPONSORSHIP Grant will be directly applied by SurgiVision Consultants Inc as a single payment, one-time, full-tuition grant of $46,745 USD applied to the All-Inclusive Program Fee to PHYSICIAN CEO 2023, pending approval of my application to participate by the PHYSICIAN CEO Executive Committee.
AFFIRMATION*

I AGREE – I affirm and agree that I have read, and agree to be bound by, the PHYSICIAN CEO Applicant/Participant Terms and Conditions of Participation as described herein.
Click Here to download and review the PHYSICIAN CEO applicant/participant Terms and Conditions of Participation.
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Contact Us

Questions about PHYSICIAN CEO? Drop us a note of telephone +1.480.664.1800. We are happy to answer any questions you may have.

Send Message

CONTACT

PHYSICIAN CEO™

28071 North 90th Way, Scottsdale, AZ 85262

480.664.1800

Guy1000@SurgiVision.net

ABOUT

The PHYSICIAN CEO™ program is developed by SurgiVision® Consultants, Inc. in collaboration with the Kellogg School of Management at Northwestern University, a top rated business school for executive education.
The PHYSICIAN CEO™ program provides an intensive, MBA-style experience to train physicians with essential Business skills.

Kellogg School of Management, Executive Education

Northwestern University

2169 Campus Drive, Evanston, IL 60208

www.kellogg.northwestern.edu/executive-education/individual-programs/executive-programs/physicianceo.aspx

PHYSICIAN CEO 2023 Program Dates

…Module 1 - January 28 - February 1, 2023

…Module 2 - April 1 - 5, 2023

…Module 3 - June 10 - 14, 2023

…Module 4 - September 16 - 20, 2023

Program Consist of All Four Modules

COMMENTS

If You own Your Own Practice You are Not Just an M.D., You are the CEO of Your Business.

Transforming the Way I Approach My Practice, Research, Innovations and Charitable Activities

As a Direct Result of this Program, I am Currently in the Process of Opening a Cash-Based Clinic

One of My Most Worthwhile Professional Endeavors

© 2022 · PHYSICIAN CEO

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