5th Stockport Ultrasound Regional Anaesthesia Workshop Booking Form

Course / Workshop Name
?
Please choose the course name
Booking date
Title
?
If you selected other please enter in the next box
Other Title
?
If the title is not available then please enter in this box
First Name
?
Please enter your first name
Last Name
?
Please enter your lastname

PLEASE PUT YOUR CONTACTABLE EMAIL ADDRESS.


PLEASE ADD admin@sasdoctors.co.uk & sas@stockport.nhs.uk to safe sender list as the email will come from this email address.

Please don't put your hospital or department number. Supply a number which we can contact easily or leave a message.


Email
?
PLEASE PUT YOUR CONTACTABLE EMAIL ADDRESS. PLEASE ADD admin@sasdoctors.co.uk & sas@stockport.nhs.uk to safe sender list as the email will come from this email address
Contactable phone number
?
Please don't put your hospital or department number a phone number which we can contact
GMC OR COLLEGE NO
?
PLEASE ENTER YOUR GMC/COLLEGE NO
Speciality
?
Your Speciality if it is not available please choose the nearest one. Gastroenterology you could choose Medicine or Surgery if you are part of surgical gastroenterology.
HospitalName
?
Hospital Name please
Address including post code ?
Address including post code
Current Post
?
Please select your current post
We will try and cater to the majority of dietary requirements. However we cannot cater for every individual needs. Please type in your requirements below
Dietary requirements ?
We will try and cater to the majority of dietary requirements. However we cannot cater every individual needs. Please type in your requirements.

Fee For Course
Click here to access and read the terms and conditions. Please read this carefully before ticking the next box. A tick in the box confirms that you have read and understood, will comply with the terms and conditions.