Patient Representatives – Conference Pass 2025 (In-Person)

Salutation *

First Name *

Last Name *

Job Title *

Organization *

Contact email *

Phone

Country *

Any dietary requirements that we should be aware of? (We cannot guarantee that dietary requirements submitted less than 10 working days before the event will be catered for).

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? Yes No

Would you like to be added to the ICHOM Newsletter list? 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. Yes No

Do you wish to find out more about becoming a sponsor of the ICHOM Conference Series? Yes No

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