Stockport ATLS course 1st, 2nd & 3rd March 2017 Booking Form

Stockport ATLS course Booking Form

Course / Workshop Name
Booking date
ARE YOU CURRENTLY WORKING IN STEPPING HILL HOSPITAL
Title
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If you selected other please enter in the next box
Other Title
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If the title is not available then please enter in this box
First Name
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Please enter your first name
Last Name
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Please enter your lastname
PLEASE TYPE IN YOUR CONTACTABLE EMAIL ADDRESS & PHONE NUMBER BELOW. 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.
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TICK THIS BOX TO CONFIRM THAT YOU HAVE READ THE ABOVE INFORMATION
Email
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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
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Please don't put your hospital or department number. Supply a number which we can contact easily or leave a message.

GMC OR COLLEGE NO
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PLEASE ENTER YOUR GMC/COLLEGE NO
Speciality
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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
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Hospital Name please
Home Address including post code (TO POST COURSE MANUAL) ?
Address including post code
Current Post
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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 to every individual needs. Please type in your requirements.
Fee for the course
I you are a foundation doctor currently working in Stockport NHS Foundation Trust, please contact Janice Good on 01614194684 to pay £500 through internal transfer.
Other doctors please contact Angela Berry on 01614194097 to make payment through credit card or send a cheque for £500 payable to "Stockport NHS Foundation Trust" to Angela Berry, Pinewood House, Stepping Hill Hospital, Stockport,SK2 7JE .
For detail terms and conditions please 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.