5th Stockport Ultrasound Regional Anaesthesia Workshop Booking Form

Booking date

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.

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

HospitalName

Hospital Name please

Address including post code ?

Address including post code

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

I will send £40 cheque payable to Stockport NHS Foundation Trust as a payment.

I will pay £40 by credit card. (Please ring Angela Berry on 01614194097)

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.

Terms & Conditions

I have read and understood the terms and conditions.