Clinical Preceptorship Program - Registration form
Ultrasound Guided Regional Anesthesia
Toronto Western Hospital Visit Program
University of Toronto
I. Registration Personal Data
* Note:
you must submit a copy of the most updated CV for Hospital observer privilege application
.
E-mail your CV to:
christine.drane@uhn.on.ca
or fax to 416-603-6494
Please complete all the fields marked with *
Title
* First Name
* Last Name
Clinic/Department/Organization
Country
* Full Address
City
State/Province
Postal/Zip Code
Telephone
Telefax
* E-mail
Scrub suit size
Top
Bottom
Please check off the fields that apply to you :
Anesthesiologist
Neurologist
Neurosurgeon
Psychiatrist
Psychologist
PMR
RN
NP
PA
Others
How did you hear about our workshop:
Colleague
Website
E-Mail
Others
II. Registration Fee
Package #1 (2 day visit)
Canadian $ 375
Available Dates for 2011
March 7-8
November 21-22
Package #2 (4 day visit)
Canadian $ 750
Available Dates for 2011
March 7-10
November 21-24
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