Congress ESL 2019

Congress ESL 2019

Page 23

Registration form (to be sent by mail or fax to the congress secretariat):

Gender

Mrs

Mr

   

Name

first name (ex: Paul)

Last name (ex: Dubois)

   

Who are you?

Student

     
 

Physiotherapist

     
 

OCP (bandagist)

     
 

Nurse

     
 

MD in training

     
 

MD specialist

     
 

Specialty-Activity?

General Practitioner

   
   

Internal Medicine

   
   

Phlebology

   
   

Angiology

   
   

Oncology

   
   

Surgery

   
   

areas of specialisation?

Plastic Surgery

 
     

Vascular Surgery

 
     

Breast

 
     

Melanoma

 
     

Gynecology

 
     

Urology

 
     

Digestive tract

 
     

Head and Neck

 
     

Other:

 
 

Company

Company Name

   
 

Other:

     

E-mail:

       

Phone-Number:

       

Fax Number:

       

Address

       
         

will participate in

the ESL meeting

the GCAFI meeting

   

will be present on

       
 

3rd May 2019

4th May 2019

3rd and 4th of May

At the Gala Dinner

         

will submit, has submitted one abstract

     
 

only for oral

only for poster

for oral and/or poster

 

as 1st author

as co-author

   

 

CERTIFICATE OF ATTENDANCE: Certificates of attendance will be available for congress participants on Saturday, May 4th, 2019.They will be given only upon reception by the congress secretariat of the meeting’s evaluation form.

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