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APELSO ADULT ECMO TRAINING COURSE 2019
Jointly organized by ELSO, Asia-Pacific ELSO, HKAM, Queen Mary Hospital & Grantham Hospital (Hong Kong)
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Registration Form
Title
*
Prof.
Dr.
Mr.
Ms.
Miss
First Name
*
e.g. Perry Tai Man (English name first)
Your answer
Last Name
*
e.g. Chan
Your answer
Position
*
Your answer
Department
*
Your answer
Institution
*
Your answer
Address
*
City; State; Country; Zip; (For sending certificate and receipt if necessary)
Your answer
Telephone
*
Your answer
Fax
Your answer
Email Address
*
We will update the program information to you by email.
Your answer
Career
*
Background Survey (The following information will facilitate our curriculum design to meet your training needs).
Doctor
Nurse
Perfusionist
Other:
Year of Experience in ECMO
*
Background Survey (The following information will facilitate our curriculum design to meet your training needs).
None
< 1 year
1-5 years
> 5 years
Other:
Current or Future Utilized Pump System
Background Survey (The following information will facilitate our curriculum design to meet your training needs.)
Centrimag
Rotaflow
Cardiohelp
Medos
Other:
Choose Our Course
*
Full course 14-17 October 2019 (course fee: USD$2,150(Overseas)/ HKD$16,500(Local))
Payment (Credit card payment or Paypal not available.)
*
(Please made payable to ''Hospital Authority'' and send the cheque or bank draft to: Ms. Viann Yu, E2 Adult Intensive Care Unit, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong)
HKD$16,500 Cheque will be submitted
USD$2,150 Bank draft will be submitted
HA department fund/ ASOI fund (for staff of HK public hospital)
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