Registration

You can register for the course by filling in the form below. After submission of this course, you will receive an email confirmation.

Please send the course fee of £450 to

Service Manager, Corneo Plastic Unit, Queen Victoria Hospital NHS Trust,
Holtye Road, East Grinstead, West Sussex, RH19 3DZ

Cheques should be made payable to "QVH NHS Trust Charitable Fund".

Personal information
Title:
Name:
First name:
Date of birth:
Sex:	male female
Professional data
Hospital name:
Hospital address:
Hospital zip code & city:
Qualifications:
Present post:
Email:
Daytime phone nr.:
Evening phone nr.:
Correspondence address (if different from hospital address)
Address:
Zip code & city:
Registration details
I will be attending the course dinner on Thursday the 8th of July 2010:	yes no
I require transport to the hotel on Thursday evening:	yes no
I have the following dietary requirement:	none vegetarian chicken fish
How did you hear about this course?
Future information	Send me information about future courses Do not send me information about future courses
Sponsors	Allow the sponsors of this course to contact me Do not allow the sponsors of this course to contact me Note: the only data we will forward to the sponsors, are your name, grade and hospital address.
	In order to submit this form, please type the letters at the left: