Moorfields Eye Hospital NHS Foundation Trust
162 City Road
London
EC1V 2PD
Clinical Electrophysiology of Vision 2016 Course
REGISTRATION FORM
Payment includes access to all scientific sessions, refreshments and lunch
Please complete clearly and in BLOCK CAPITALS
Please note that your registration will not be confirmed without full payment via cheque or credit/debit card (please see page two)
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Date registered with the GMC: / GMC/GOC/NMC number
Special requirements needed:
Dietary requirements needed:
Registration – office use only
Amount paid / £790 / £690 / Method / Cheque / Credit / Debit
Initial&Date entered onto intrepid / Initial&Date sent joining instructions
Payment Details: / Please tick () relevant box. All payments to be in GB Pounds Sterling. Registrations will NOT be accepted without full payment.
By Cheque/Bank Draft / Payable to “Moorfields Eye Hospital NHS Foundation Trust”.
Overseas bankers cheque drawn on a UK bank in pounds £ sterling cheque for holders of a UK bank account.
Please deduct the total sum due from: /
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Debit Card: Visa Delta Switch/Maestro
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Only submit your registration form once by email (), or post; Courses - Postgraduate Medical Education Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London EC1V 2PD, United Kingdom.
By returning your completed registration form and payment details you are agreeing to the registration procedures and regulations of Moorfields Eye Hospital NHS Foundation Trust (MEH), including any cancellation policies for registration fees costs. You are also agreeing to your name and current position being included on the list of participants circulated at the course.
MEH does not accept any responsibility for any personal or financial information submitted before it is received by us. This is done so at your own risk. Once received, we process the data under data protection legislation.
NB: please review our courses pages for details of cancellation fees and notice period.
Certificates of attendance are only awarded after the final session of a course. Please bear this in mind when making your travel arrangements.
SIGNED: …………………………………………. DATE: …………………………………
Clinical Electrophysiology of Vision Course, 16/04