Registration Form
Personal information
*
Name
Surname
Fiscal code
*
If not applicable, please digit 000
Affiliation
*
Entity, Hospital, University
Contractual Form
*
Please Select
Employee
Freelance
Affiliated with SSN
Affiliated with Other
Disoccupied
Student/Resident
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Field
*
Please Select
Anato-Pathology
Audiology
Maxillo-facial surgery
Plastic and reconstructive surgery
Otolaryngology
Medical Oncology
Radiation Oncology
Radiologist
Medical radiology healthcare technician
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Please indicate if you have been recruited by a commercial company operating in the healthcare sector:
*
Please Select
Yes
No
A healthcare professional is considered to be recruited if he/she benefits from direct and indirect economic and non-economic advantages from commercial companies operating in the healthcare field for participation in training events,
Please indicate the company
Contact information
*
E-mail address
Phone number
Special needs
Please indicate allergies, intolerances, special dietary needs or any other needs
Registration Fees
*
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( X )
Whole course - Physician - Fee reserved to SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 1.650,00 €
€
1,500.00
Whole course - Physician
Fee valid until 15th June 2025. From 16th June 2.200,00 €
€
2,000.00
Whole course - Resident
Fee valid until 15th June 2025. From 16th June 1.200,00 €
€
1,000.00
Whole course - Resident - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 900,00 €
€
750.00
Whole course - Radiology Technician
Fee valid until 15th June 2025. From 16th June 600,00 €
€
500.00
Single module - Physician
Fee valid until 15th June 2025. From 16th June 450,00 €
€
380.00
Single module - Physician - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 5230,00 €
€
325.00
Single module - Resident
Fee valid until 15th June 2025. From 16th June 250,00 €
€
200.00
Single module - Resident - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 213,00 €
€
170.00
Single module - Radiology Technician
Fee valid until 15th June 2025. From 16th June 170,00 €
€
130.00
Two modules - Physician - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 723,00 €
€
604.00
Two modules - Physician
Fee valid until 15th June 2025. From 16th June 850,00 €
€
710.00
Two modules - Resident - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 425,00 €
€
340.00
Two modules - Resident
Fee valid until 15th June 2025. From 16th June 500,00 €
€
400.00
Two modules - Radiology Technician
Fee valid until 15th June 2025. From 16th June 220,00 €
€
180.00
Three modules - Physician - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 1.040,00 €
€
880.00
Three modules - Physician
Fee valid until 15th June 2025. From 16th June 1300,00 €
€
1,100.00
Three modules - Resident - Discount for SIRM members - H&N Group
Fee valid until 15th June 2025. From 16th June 600,00 €
€
480.00
Three modules - Resident
Fee valid until 15th June 2025. From 16th June 750,00 €
€
600.00
Three modules - Radiology Technician
Fee valid until 15th June 2025. From 16th June 380,00 €
€
340.00
Select the payment method:
*
Bank transfer (the secretariat will send the details via e-mail)
Online credit card (the secretariat will send a personal link via e-mail)
Invoicing information
*
Header of the invoice
Fiscal address: street, town, postal code
Date and place of birth
VAT number (if applicable)
Any notes
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