R E G I S T R AT I O N F O R M
To complete and send to: n. 06.88.45.354 fax or e-mail at: [email protected]
1st EUROPEAN ADVANCED COURSE ON SURGICAL TECHNIQUES FOR SNORING AND OSAHS
4 Steps of live surgery and a course of laboratory anatomical dissection
Coordinator: Fabrizio Ottaviani
Course Directors: Gianluca Bellocchi, Andrea Marzetti, Francesco Peverini
Scientific Committee: Michele de Benedetto, Nico de Vries, Desiderio Passali, Claudio Vicini
This Course is a EOS DRS continuous and integrated training project advanced module.
Rome, Ospedale San Carlo, Azienda Ospedaliera San Camillo Forlanini
Calendar of Educational Sessions
• 08-09/10/2015 - 10/10/2015 (Anatomical dissection I Group)
• 03-04/12/2015 - 05/12/2015 (Anatomical dissection II Group)
• 11-12/02/2016 - 13/02/2016 (Anatomical dissection III Group)
• 14-15/04/2016 - 16/04/2016 (Anatomical dissection IV Group)
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Hospital______________________________________________________________________________
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Date
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Enrollment to:
■ Single Step € 700 + VAT 22% = € 854
■ Single Step + 1 Anatomical Dissection Step € 1.100 + VAT 22% = € 1.342
■ 2 Steps € 1.400 + VAT 22% = € 1.708
■ 2 Steps + 1 Anatomical Dissection Step € 1.800 + VAT 22% = € 2.196
■ 3 Steps € 2.100 + VAT 22% = € 2.562
■ 3 Steps + 1 Anatomical Dissection Step € 2.500 + VAT 22% = € 3.050
■ Advanced Course (4 Steps) € 2.500 + VAT 22% = € 3.050
■ Advanced Course (4 Steps)
+ 1 Anatomical Dissection Step € 3.000 + VAT 22% = € 3.660
Signature
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For the enrollment to 1, 2 or 3 steps please indicate the chosen dates
08-09/10/2015
03-04/12/2015
11-12/02/2016
14-15/04/2016
Please indicate the chosen date for the Anatomical Dissection Step
■ 10/10/2015 ■ 05/12/2015 ■ 13/02/2016 ■ 16/04/2016
■ 1st Step
■ 2nd Step
■ 3rd Step
■ 4st Step
• For postgraduate students the anatomical dissection step is free of charge
when subscribing to the entire course.
• Payment can be made in 2 installments, the first immediately and the second
by the end of December, for those who enrolled to the entire course, whereas
for the others it will be an advance payment in a single solution.
Registration Fee includes: • Course attendance • ECM Certificate
Payment method: by Bank transfer: Banca Intesa S. Paolo - IBAN code IT46S0306903202100000032046 - Swift code BCITITMM - Mediprint s.r.l. a socio unico
This registration form fully filled and signed allows you to perform all the obligations prescribed by the Ministry of health for ECM accreditation. The data collected will be treated
as confidential in compliance with D.Lgs n° 196/2003. SELF CERTIFICATION. I hereby declare to have fully attended the congress. In this way i’m complying to the requirements of
presence by ECM ministerial regulation, binding for granting the credits assigned to the event.
Date
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