Basic Clinical Skills in Ophthalmology and Ophthalmology Taster Day

5^th January 2019

Central Middlesex Hospital London

Register for the Course

To ensure that confirmation of place is not delayed, could you kindly state if you are registering and paying for this course/event for yourself or on behalf of someone else?

I am registering and paying for myself

I am registering and paying on behalf of someone

Please provide the DETAILS OF THE STUDENT/DOCTOR on behalf of whom you are registering and paying:

Title

Gender

Please ensure that you enter your name accurately since it will be printed on your name badge and certificate.

Forename

Surname

Address

Kindly ensure that you enter your full and accurate postal address since the books will be dispatched to this address. Incorrect address may result in delay or failure of delivery of the books. If you reside outside the United Kingdom the books will be given to when you attend the course.

Pin code/Post code/ Zip code

Landline Number

Please select whether the candidate is a doctor or medical student.

Medical Student

Doctor

Your registration is not complete and your place in course will not be confirmed until all fields are completed.

Please provide YOUR DETAILS so that we can match the payment with the candidate's details in our system.

Forename

Surname

Address

Country

Pin code/Post code/ Zip code

Phone number (including country code if outside the UK)

Please state your relation to this candidate