WeBSurg, the e-surgical reference in Laparoscopy

With the partnership of

KARLSTORZ
Inventor & designer of Medical instruments

Covidien

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Registration form


Advanced Course in Colorectal Surgery
June 25th - June 26th 2010


Please note that if you have already registered online or if you are a WeBSurg member,
you should log in to have the following form pre-filled.


(*) Compulsory fields
PERSONAL DATA
* Gender:
* Family name:
* First name:
* Title:
* Date of birth
(yyyy-mm-dd)
* Specialty:
Mobile phone:

* Please enter at least one of the following addresses:
   

Private address
* Email:
* Postal address:
Zip code:
* City:
Cedex:
State:
* Country:
* Phone:
Fax:

Hospital address
* Email:
* Institution/Hospital:
* Postal address:
Zip code:
* City:
Cedex:
State:
* Country:
* Phone:
Fax:

Clinical practice address
* Email:
* Postal address:
Zip code:
* City:
Cedex:
State:
* Country:
* Phone:
Fax:

CREATE YOUR USERNAME AND PASSWORD
(minimum 6 alphanumeric characters)
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* Password:
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REGISTRATION
   
   

HOTEL ACCOMMODATION
preferential rate at a Strasbourg 4 star hotel



mention the dates: