GERMAN CTO & CHIP MEETING - Request for grant support

Family name*

First name*

E-mail adress*

Cell phone number*

Cell phone number (only) Please indicate in front of your phone number, the country dialling code of your country.

Affiliated Medical Center*

Country*

City*

REGISTRATION

I register as :*

Physician
Fellow
Paramedics

N° RPPS (only for french physician/paramedic)*

If you do not have an RPPS number, please note in this section "N/A".

What do you perform in your daily practice ?*

Coronary angioplasty
Peripheral angioplasty
Structural heart interventions
Rhythmology
Interventional radiology
Endovascular procedures
Interventional radiology
Vascular surgery
Cardiac surgery

How many percutaneous coronary interventions are performed per year in your center?*

Do you have a CTO PCI program in your cath lab?*

Yes
No

How many CTO PCI have been performed during 2023 in your center?*

How many CTO PCI did you personally perform during 2023 ?*

How many CTO PCI do you consider performing this year?*

How have you heard about the 1st edition of GERMAN CTO & CHIP Meeting*

Newsletter
Website (browser)
Social media
Industry
Peer
Other

Please indicate which industry and country ?

Other (please specify)*

What are the reasons why you want to attend this Course?*

ACCOMMODATION

Select the number of night(s) you would like to stay*

Night of February 15th (February 15th to 16th, day before the congress)
Night of February 16th (February 16th to 17th)
I don't need accommodation

This package includes a single room for two nights at the hotel. All the information concerning your hotel will passed on to you before the event.

Special accommodation requests

TRANSPORT

Airport and/or station tranfers will be handled by the organization. You will receive detailed information in your travel book few days before your departure by email.

Your flight will be in economic class, if you wish to travel in business class, it will be to your own charge.

Do you need a transportation booking?*

Yes
No

Departure city*

Departure date*

Departure time*

Morning
Afternoon
Evening

Return city (if it is not departure city)

Return date*

Return time*

Morning
Afternoon
Evening

Membership card type and number (airline, railroad company...)

Preferred Airline company

Upload your passport or ID Card*

Types de fichiers acceptés : jpeg, jpg, png, pdf, gif, Taille max. des fichiers : 128 MB.

Essential to book your travel. Thanks.

Special travel requests (aisle, window...)

Phone

Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.