Registration form for the AXTC courses
Please print this registration form and send or fax completed signed form to: Attn. Ms. Mirel Bosman fax: +31 50 5254386
| International ARTISAN® / ARTIFLEX® Phakic IOL Training Session Registration: | |
| Mr. / Mrs. / Ms. | |
| Name: | ...................................................................................... |
| Initials: | ...................................................................................... |
| Title's | ...................................................................................... |
| Practice Name: | ...................................................................................... |
| Address | ...................................................................................... |
| City, Zip: | ...................................................................................... |
| Country: | ...................................................................................... |
| Phone: | ...................................................................................... |
| Fax: | ...................................................................................... |
| E-mail: | ...................................................................................... |
| Kind of training: | |
| O | Basic ARTISAN Course, Fee US $ 2500,- |
| O |
Combination ARTISAN/ARTIFLEX Course, Fee US $ 3000,- |
|
Date: |
|
| O | |
| O | |
| O |
|
| Credit card: (Please note that credit card companies charge an additional 5,8% commission) | |
| O | Visa |
| O | American Express |
| O | EC/MC |
| Credit card number:.......................................... | |
Safety Code: ............................. (on the back of the card, in the signature area, the last three number are the safety code) |
|
| Expires:...................................................................................... | |
| Signature:...................................................................................... | |
| I am aware that places will be assigned in order of receipt of payment. | |
07/08/08
Successful meeting during WOC
For the first time Ophtec organized an Asian ARTISAN/ARTIFLEX user meeting. This meeting was arranged during the World Ophthalmic Congress (WOC) in Hong Kong June 2008.
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