PHYSICIAN CEO Online 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
- 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
- Acara Partners
- 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
- Heart Rhythm Society
- Industry Meeting
- Kellogg School of Management / Northwestern University
- MillennialEYE / MELive
- PHYSICIAN CEO Alumni / Attendee
- RSA - Refractive Surgery Alliance Society
- ShoutMD
- Web Search
- WPO - World Physicians Organization
- 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 2022 PROGRAM DATES

Program Fee Includes:

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

February 5 - February 9, 2022

April 2 - 6, 2022

June 18 - 22, 2022

September 10 - 14, 2022

• 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 2022 PROGRAM FEE*

$44,100.00 USD - All Inclusive Program Tuition for PHYSICIAN CEO 2022.
Group ID... (Optional)
RSA MEMBER PREFERRED PRICING - PHYSICIAN CEO 2022 PROGRAM FEE*

$37,485.00 USD - "RSA MEMBER RATE" All Inclusive Program Tuition for PHYSICIAN CEO 2022. RSA Preferred Member Rate is calculated as $44,100 Program Tuition less 15% RSA MEMBER SAVINGS ($6,615) equals $37,485 Program Tuition.
DATALINK PREFERRED PRICING - PHYSICIAN CEO 2022 PROGRAM FEE*

$37,485.00 USD - "DATALINK PREFERRED RATE" All Inclusive Program Tuition for PHYSICIAN CEO 2022. DataLink Preferred Rate is calculated as $44,100 Program Tuition less 15% DATALINK SAVINGS ($6,615) equals $37,485.00 All-Inclusive Program Tuition.
AID PREFERRED PRICING - PHYSICIAN CEO 2022 PROGRAM FEE*

$37,485.00 USD - "AID PREFERRED RATE" All Inclusive Program Tuition for PHYSICIAN CEO 2022. AID Preferred Rate is calculated as $44,100 Program Tuition less 15% AID SAVINGS ($6,615) equals $37,485.00 All-Inclusive Program Tuition.
PCEO ALUMNI GRANT - PREFERRED PRICING for PHYSICIAN CEO 2022 PROGRAM*

$36,600.00 USD - "PCEO ALUMNI GRANT RATE" All Inclusive Program Tuition for PHYSICIAN CEO 2022. PCEO Alumni Grant Rate is calculated as $44,100 Program Tuition less ALUMNI GRANT SAVINGS ($7,500) equals $36,600 Program Tuition.
ROBERT GRANT "GRANT" - PREFERRED PRICING for PHYSICIAN CEO 2022 PROGRAM*

$26,460.00 USD - ROBERT “GRANT" All Inclusive Program Tuition for PHYSICIAN CEO 2022. Robert "Grant" Rate is calculated as $44,100 Program Tuition less ROBERT "GRANT" SAVINGS ($17,640) equals $26,460 Program Tuition.
CHARITABLE ORGANIZATION / PHILANTHROPIC PRICING - PREFERRED PRICING for PHYSICIAN CEO 2022 PROGRAM*

$22,050.00 USD - "Charitable Organization / Philanthropic Endeavors Rate" All Inclusive Program Tuition for PHYSICIAN CEO 2022. Charitable Organization / Philanthropic Endeavors Rate is calculated as $44,100 Program Tuition less 50% Charitable Organization / Philanthropic Endeavors SAVINGS ($22,050) equals $22,050 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.

Twelve (12) Equal Payments - I Elect to Pay the Balance of the Tuition Payment as Twelve 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 Twelve Months, Payable by Major Credit Card (using PayPal), Check, Wire Transfer, or Money Order.
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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PHYSICIAN CEO Application