Workshops - Registration form

Ultrasound Guided Regional Anesthesia
Toronto Western Hospital Visit Program
University of Toronto

I. Registration Personal Data

Please complete all the fields marked with *
Title * First Name * Last Name
Clinic/Department/Organization
* Full Address
City State/Province
Country Postal/Zip Code
Telephone Telefax * E-mail
* Special Meal Requirement
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

Machine Requirement (BK Medical, GE (Full), Philips, Sonosite (Full), Zonare)
II. Registration Fee
Workshops Available Dates for 2011
Please select date
November 18-19, 2011


 

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