GEST MSK 2024 - Request for a 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
Intern
Paramedics

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

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

Did you attend the GEST MSK 2023 meeting in Paris?*

Yes
Non

Do you currently perform MSK embolization?*

Yes
Non

Please indicate what procedures and how many you have done until now : GEA*

Less than 5 cases
5-9 cases
More than 10 cases

Frozen Shoulder*

Less than 5 cases
5-9 cases
More than 10 cases

Epicondylitis*

Less than 5 cases
5-9 cases
More than 10 cases

Other (please specify procedure name and number of cases)

Based on what you know, which of the following companies have products or will be introducing products for embolotherapy in MSK in the next year?*

Guerbet
Merit Medical
Terumo
Boston Scientific
Cook Medical
Varian
Other (please specify)

Other (please specify)*

What embolic material(s) have you been using?*

Embosphere
Embozene
Lipiodol emulsion
Imipenem-cilastatin
Other

Other (please specify)*

What embolic material(s) would you like to use in the coming year?*

Embosphere
Embozene
Lipiodol emulsion
Imipenem-cilastatin
Other

Other (please specify)*

What is your preferred microcatheter?*

What is the main limitation for you to start/grow your practice?*

Not confident enough
Not enough evidence
No referral by rheumatologist/orthopedic
No access to an embolic in which I am confident
Not convinced that this will work

In what ways can we help you in overcoming the limitation you mentioned?*

How knowledgeable would you say you are about performing MSK procedures?*

I'm a newbie
More to learn
I'm an expert

How would you like to learn more about MSK procedures? Check all that apply.*

An MSK Online Community
In-depth, interactive webinars on MSK
MSK focused In-person meeting
Visit an expert center and attend cases
A certificate program to build your practice

Do you have access to Imipenem Cilastatin?*

Yes
No

How long have you been a practicing physician?*

In what country do you practice?*

What is your area of specialty*

Interventional Radiology

What is your practice setting?*

Academic
Private Practice
VA/Government
For profit hospital/health system
Not for profit hospital/health system

ACCOMMODATION

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

Night from January 26th to 27th
Night from January 27th to 28th
I do not need an 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...)

We will reimburse you up to :
- France : 450€
- Out of France : 750€
Thank you for sending your receipts and your bank details after the congress to :
j.lechaffotec@comnco.com

We will proceed to your refund by bank transfer within 4 weeks after the conference depending of your departure country. If you use your personal vehicle, the allowances of refund will be calculated on a standard kilometers referral.

Comments

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