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Echo-Medanta 2012 A comprehensive teaching course on echocardiography 6 th -8 th September, 2012 Registration form Name: ___________________________________________ Age:_______ Years Gender: M/F Medical Qualifications:_____________________________________________________________________________ Address: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ City_____________________, State___________________________ Pin Code________________ Email: _____________________________________________ Phone/Mob:_________________________________ What type of set-up are you working for? Medical College Non-teaching Govt. Hospital Large Pvt. Hospital Nursing Home Your Own Clinic Already performing echocardiography? ______________(Yes/No), If yes, what duration?__________ Any formal training?___________________________________________________________________________________ Membership of any professional organization? Indian Academy of Echocardiography (IAE) Cardiological Society of India (CSI) Association of Physicians of India (API) Other___________________________________ Enclosed is the Cheque/DD no _____________________, of Rs 5000/-, bank name and branch______________________________________________________, dated ________________________payable at New Delhi, in favor of “Global Health Private Limited”. Mail this form at: Dr. Ravi R Kasliwal Room no. 9, 3rd floor, Medanta - The Medicity, Sector – 38, Gurgaon, Haryana – 122001, INDIA. For enquiries contact: Ms Sarlla Shakya +91-8800494247 Ms Archana Mirgan +91-9971698197 Email: [email protected]
