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 * Full Address City State/Province Country Postal/Zip Code Telephone Telefax * E-mail * Special Meal Requirement (If none please enter N/A) 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 Continuous Nerve Block Workshop Available Dates for 2012 Please select date January 27, 2012 May 25, 2012

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