Live Advanced Laparoscopic Colorectal Course

Prince Charles Hospital, Merthyr Tydfil, Wales

Registration Form

Title

Gender

Please ensure that you enter your name accurately since it will be printed on your name badge and certificate.

Enter your first name E.g., Anthony Mathew Jones (first name in red)

Enter any middle name(s) E.g., AnthonyMathew Jones (middle name in red)

Enter your surname E.g., Anthony MathewJones (last name in red)

Address

Pin code/Post code/ Zip code

Landline Number

Mobile Number

Email 1

Email 2

All future correspondence regarding the course will be sent via email. Hence please ensure that you provide the one(s) you check regularly.

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Your Professional Status

Hospital

Current Affiliation

Please enter your level of training/experience

If you are a post MRCS surgical trainee working in the UK National Health Service, would you like to apply for an educational grant that may be provided by Ethicon Endo-Surgery, Doctors Academy or Prince Charles Colorectal Department?

Yes

Need Help?

Please email us at contact@doctorsacademy.org.uk if you experience any difficulties during the registration or payment process. One of our support staff will get in touch with you immediately.
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