Registration form

Please fill in the registration form below and make a payment following the instructions you will receive in e-mail.

Participant information

Salutation *

First name *

Last name *

Academic title

Medicine license no

Phone *

E-mail *

Participant type *

Workshop

Hotel accommodation

Without hotel accommodation

Comment

Address

City

Zip code

Country

Institution

Institution *

Department *

Street *

Zip code *

City *

Phone

Invoicing data

Number of invoices

One Two

Applicant

Individual
Company

Company name or surname *

Street *

City *

Zip code *

Tax identification number / VAT number

Country *

Applicant

Individual
Company

Company name or surname *

Street *

City *

Zip code *

Tax identification number / VAT number

Country *

Order summary

Total amount

Additional information

I hereby give consent for my personal data included in the registration form to be processed for the conference purposes and processing them by Medisfera Marcin Zabawa, located at ul. Kraszewskiego 85 C m. 7, 05-400 Otwock under the Data Protection Act 1997 (Journal of Laws 2002, no. 101, item 926, consolidated text with later amendments). As a client I am eligible to review and edit my personal data.

I hereby give consent to receive commercial information sent via email by Medisfera Marcin Zabawa, located at ul. Kraszewskiego 85 C m. 7, 05-400 Otwock under the Act on Electronic Provision of Services of 18 July 2002 (Journal of Laws 2002, no.144, item 1204, as amended). The consent can be withdrawn at any time.