$2,095.00 ex VAT
Salutation *
First Name *
Last Name *
Job Title *
Organization *
Contact email *
Phone
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Any dietary requirements that we should be aware of? (We cannot guarantee that dietary requirements submitted less than 20 working days before the event will be catered for).
What other events do you attend throughout the year? (If none, put none)
Are you a member of a healthcare association? Please list all memberships
Company Size Choose an option * 1-10 employees 11-50 employees 51-200 employees 201-500 employees 501-1,000 employees 1,001-5,000 employees 5,001-10,000 employees 10,000+ employees
From time to time, ICHOM may wish to contact you regarding products and services from other organisations which we think may be of interest to you. Do you wish to be contacted? Choose an option * Yes No
Would you like to be added to the ICHOM Newsletter list? Choose an option * Yes No
From time to time, ICHOM may use your name, job title and organization for networking purposes. Please tick this box if you do not wish for us to do so. Choose an option * Yes No
Do you wish to find out more about becoming a sponsor of the ICHOM Conference Series? Choose an option * Yes No
Please choose what best describes your expertise / interest Choose an option * Oncology Muskoskeletal Cardiometabolic Maternal - Child Health Mental Health Ophthalmology Life-course Other
Has your organization implemented ICHOM Sets of Patient-Centered Outcome Measures? Choose an option * Yes, we have implemented one or more ICHOM set(s) We are in the process of implementing No, we have not implemented ICHOM Sets
Which category best describes your organization? Choose an option * Provider of Healthcare Industry (Other) Industry (Pharma) Industry (MedTech) Charity Academic Patient / Patient Group Government Regulatory Body / Professional Bodies / Associations Insurance
St.Antonius Hospital Travel
