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Advancing the Science of Ultrasound Guided Regional Anesthesia and Pain Medicine

1st National Neuropathic Pain Day

I. Registration Personal Data
Title
* First Name
* Last Name
Clinic/Department/Organization
* Full Address
* City
State/Province
* Country
Postal/Zip Code
* E-mail
Telephone
* Special Meal Requirement (If none please input N/A)
Allergies
Payment

Please check off the fields that apply to you :

Anesthesiologist
Neurologist
Neurosurgeon
Psychiatrist
Psychologist
PMR
RN
NP
PA
Others

Personal Information is collected on registration form pursuant to section 26 of the Freedom of Information and Protection of Privacy Act, RSBC 1996 c. 165. Information is used for the purposes of facilitating the conference and collecting aggregate statistics.

All participants registered for this course are included on the contact list for future programs. If you DO NOT wish to have the organizers contact you, please indicate below.

I DO NOT wish to be on the contact list

II. Registration Fee

Physicians and Health Care Professionals - $400
Residents, Fellows, Researchers in-training, or medical students - $200*
*Residents/Students must provide proof of training on-site
Cheques for registration should be made out to "Toronto Western Hospital - Regional" (reference in Memo: Neuropathic Pain Day 2017), and should be mailed to:

Ms. Christine Drane, Department of Anesthesia and Pain Management, McL 2-405
399 Bathurst Street, Toronto, Ontario, M5T 2S8


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