REGISTRATION FORM

BOSMAC
BOSMAC ATTENDEES
• Pre-Op Patients: This conference is targeted towards United States families wanting to learn more about microtia ear reconstruction and implanted hearing devices. Please only register if you are able to come to the entire BOSMAC event – 8:30am Friday morning conference AND Friday or Saturday Individual Patient Appointments/3D scanning (and even catch a baseball game!). You will need to plan any travel and work schedules accordingly. If you are only available for an Individual Patient Appointment, or if you are an international patient, then please email info@lewinmd.com to schedule a standard Zoom consultation instead due to the limited availability and scope of the conference.

• Post-Op Patients: If you are a post-op interested wanting to participate on our Patient Panel, please email info@lewinmd.com to be placed on our waiting list. Due to an overwhelming amount of families interested in wanting to give back, we will do a random drawing in April. Please do not register below as it is only for pre-op families. Thank you in advance!

If you attended CHIMAC 2024 please wait for General Registration to open on March 24th.
Patient*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Mother's Name
First Last
Father's Name
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Attendees
Names of all family members (click plus sign to add more names)*
First Name Last Name Age (if Minor) as of 8/1/25
Release/Waiver
Photography and videography release*
Earicles and Dr. Sheryl Lewin documents conferences and events through photography and videography for our attendees to enjoy, for future use in educating families about our events, as well as to spread awareness about microtia. We typically put together a fun, post-event wrap-up video (see sample on event website). This is very important to us and we appreciate your help.

Earicles, Dr. Sheryl Lewin, venue and vendors may use those photographs or video footage for their training/marketing/social media purposes.

Yes, you may photograph/videotape all of the above persons and use for training/marketing/social media purposes
Event waiver*
By checking the box, I release Earicles, Dr. Sheryl Lewin, and any individual event staff persons from any claim or liability related to that use and waive all claims for myself, my heirs and assignees against them.

Waiver release checkbox
If you have questions or concerns about the Release/Waiver, please do not continue with registration and email info@lewinmd.com
T-Shirt Size
Pick size of free T-shirt*
Individual Patient Appointments (IPAs)
Families requesting an IPA with Dr. Sheryl Lewin will need to create a Patient Portal account, upload photos, complete medical history forms, etc. This allows the consultation to be as efficient and effective in the time allowed. An email with instructions will be sent after you register for the conference. IPAs are booked on a first-come, first-serve basis AFTER all required steps are completed. The exact appointment times will be emailed by July 15, 2025. Please note that IPAs are intended to be a BRIEF INTRODUCTION and are strictly 13-15 minutes long to fairly accommodate all families. More in-depth follow-up conversations can occur at a later date.

Please select your top 2 options. If you only select one option, we may not be able to accommodate you.
Individual Patient Appointments:
- Friday, August 1, 2025 1:30p-5:00p
- Saturday, August 2, 2025 8:00a-12:00p
- Saturday, August 2, 2025 1:00p-3:45p
(Must select at least 2 options)
Additional T-shirts
Unisex T-Shirts
- Click here to order additional T-Shirts ($20)
Youth XS Quantity
Price: $20.00
Youth S Quantity
Price: $20.00
Youth M Quantity
Price: $20.00
Youth L Quantity
Price: $20.00
Adult S Quantity
Price: $20.00
Adult M Quantity
Price: $20.00
Adult L Quantity
Price: $20.00
Adult XL Quantity
Price: $20.00
Adult XXL Quantity
Price: $20.00
Adult XXXL Quantity
Price: $20.00
Registration
Registration Fee
Price:
The Registration Fee is for 2 adults and 2 children (ages 2 and over). Each additional family member attending the Friday morning conference at Fenway is $35. Quantity
Price: $35.00
Comments/Questions
Early Registration Coupon
Total
$0.00
Cancellation
We have a no cancellation policy and cannot refund the registration fee due to any cancellations. Please consider your registration fee a donation to our non-profit, Earicles. Please check with the Courtyard Downtown Boston regarding their specific hotel cancellation policy.

*For those needing overnight accommodations, we require attendees book within our Earicles group block at the Courtyard Downtown Boston as part of the conference registration process. We have secured a discounted, negotiated group rate to make the event more affordable for our families, but also with a minimum number room requirement.

Next Steps After clicking "REGISTER" you will be directed to PayPal. You may use a PayPal account or any major credit card to pay. Once you have paid the fee, we will send you detailed information about securing Individual Patient Appointments, discounted Hotel and Red Sox baseball ticket information. We look forward to meeting you in Boston!

REGISTRATION FORM

Contact Information
If you are a post-op patient interested in attending CHIMAC, unfortunately our Patient Panel is already completely filled due to immediate interest. We are so grateful for so many families wanting to give back!. Due to the limited weekend schedule and availability, this specific event is only for new pre-op families. Please stay tuned for future conferences if you are interested in attending!

If you are an international patient interested in attending CHIMAC, please email info@lewinmd.com and we can schedule you for a Zoom consultation instead due to the limited availability of this conference.
Patient*
First Last
Patient Date of Birth*
MM slash DD slash YYYY
Mother's Name
First Last
Father's Name
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Attendees
Names of all family members (click plus sign to add more names)*
First Name Last Name Age (if Minor) as of 8/9/24
Release/Waiver
Photography and videography release*
Earicles and Dr. Sheryl Lewin documents conferences and events through photography and videography for our attendees to enjoy, for future use in educating families about our events, as well as to spread awareness about microtia. We typically put together a fun, post-event wrap-up video (see sample on event website). This is very important to us and we appreciate your help.

By checking the box, I agree that the event photographers may photograph or videotape me, and my family members listed above. Earicles and Dr. Sheryl Lewin may use those photographs or video footage for their training/marketing/social media purposes.

Yes, you may photograph/videotape all of the above persons and use for training/marketing/social media purposes
Event waiver*
By checking the box, I release Earicles, Dr. Sheryl Lewin, and any individual event staff persons from any claim or liability related to that use and waive all claims for myself, my heirs and assignees against them.

Waiver release checkbox
If you have questions or concerns about the Release/Waiver, please do not continue with registration and email events@lewinmd.com
T-Shirt Size
Pick size of free T-shirt*
Individual Patient Appointments (IPAs)
Families requesting an IPA with Dr. Sheryl Lewin will need to create a Patient Portal account, upload photos, complete medical history forms, etc. An email with instructions will be sent after you register for the conference. IPAs are booked on a first-come, first-serve basis after ALL steps are completed. The exact appointment times will be emailed July, 2024. Please note that IPAs are intended to be a BRIEF INTRODUCTION and are strictly 13-15 minutes long to fairly accommodate all families. More in-depth follow-up conversations can occur at a later date.

Please choose your IPA preference day/time.If the patient is eligible for a 3D scan, this may occur after the appointment or at a set time on the same day. There will be no additional fee for this scan. Please select your top 2 options:
Individual Patient Appointments:
- Saturday, August 10, 2024 8:00a-12:00p
- Saturday, August 10, 2024 12:00p-4:00p
- Sunday, August 11, 2024 8:00a-12:00p
- Sunday, August 11, 2024 12:00p-4:00p
(Select two only)
Additional T-shirts
Unisex T-Shirts
- Click here to order additional T-Shirts ($20)
Youth XS Quantity
Price: $20.00
Youth S Quantity
Price: $20.00
Youth M Quantity
Price: $20.00
Youth L Quantity
Price: $20.00
Adult S Quantity
Price: $20.00
Adult M Quantity
Price: $20.00
Adult L Quantity
Price: $20.00
Adult XL Quantity
Price: $20.00
Adult XXL Quantity
Price: $20.00
Adult XXXL Quantity
Price: $20.00
Women's V-neck LAMAC T-shirts
- Click here to order Women's V-neck LAMAC t-shirts ($30).
Women's XS Quantity
Price: $30.00
Women's S Quantity
Price: $30.00
Women's M Quantity
Price: $30.00
Women's L Quantity
Price: $30.00
Women's XL Quantity
Price: $30.00
Women's XXL Quantity
Price: $30.00
Registration
Registration Fee
Price:
The Registration Fee is for 2 adults, and 2 children (ages 2 and over). Each additional family member attending the Friday night Ice Cream Social is $30. Quantity
Price: $30.00
Comments/Questions
Early Registration Coupon
Total
$0.00
We have a no cancellation policy and cannot refund the registration fee due to any cancellations. If you are not able to attend the conference, your fee will be considered a tax-deductible donation to Earicles and upon request a letter will be sent to you documenting the donation. Please email info@lewinmd.com with any questions about this policy. Please check with the Palmer House Hotel regarding their specific cancellation policy.

After clicking "REGISTER" you will be directed to PayPal. You may use a PayPal account or any major credit card to pay. Once you have paid the fee, we will send you detailed information about Hotel Reservations and Individual Patient Appointments. *For those needing overnight accommodations, we strongly encourage you to book within our group block at the Palmer Hotel as part of the conference registration process.

First Name	Last Name	Age (if Minor) as of 8/1/25

First Name	Last Name	Age (if Minor) as of 8/9/24

REGISTRATION FORM

BOSMAC

Attendees

Release/Waiver

T-Shirt Size

Individual Patient Appointments (IPAs)

Additional T-shirts

Registration

REGISTRATION FORM

Contact Information

Attendees

Release/Waiver

T-Shirt Size

Individual Patient Appointments (IPAs)

Additional T-shirts

Registration