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 AIOCC, AIRO, AOLPI, AOOI, AUORL, SIAPEC, SIOeChCF, SICMF, SIRM members
€280.00
€
280.00
Whole course - Physician
€350.00
€
350.00
Whole course - Resident - Fee reserved to AIOCC, AIRO, AOLPI, AOOI, AUORL, SIAPEC, SIOeChCF, SICMF, SIRM members
€200.00
€
200.00
Whole course - Resident
€250.00
€
250.00
Single module - Physician - Fee reserved to AIOCC, AIRO, AOLPI, AOOI, AUORL, SIAPEC, SIOeChCF, SICMF, SIRM members
€120.00
€
120.00
Single module - Physician
€150.00
€
150.00
Single module - Resident - Fee reserved to AIOCC, AIRO, AOLPI, AOOI, AUORL, SIAPEC, SIOeChCF, SICMF, SIRM members
€88.00
€
88.00
Single module - Resident
€110.00
€
110.00
Two modules - Physician - Fee reserved to AIOCC, AIRO, AOLPI, AOOI, AUORL, SIAPEC, SIOeChCF, SICMF, SIRM members
€200.00
€
200.00
Two modules - Physician
€250.00
€
250.00
Two modules - Resident - Fee reserved to AIOCC, AIRO, AOLPI, AOOI, AUORL, SIAPEC, SIOeChCF, SICMF, SIRM members
€160.00
€
160.00
Two modules - Resident
€200.00
€
200.00
Note
If chosen one or two modules, please indicate which ones you're interested in
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
Send
Should be Empty: