MLCTO 2021 - REGISTRATION FOR A DIGITAL PARTICIPATION

Family name*

First name*

E-mail adress*

Date of birth*

Cell phone number*

Affiliated Medical Center*

City*

Country*

I would like to register for a digital participation as :*

Please indicate your RPPS Number*

What do you perform in your daily practice ?*

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

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

How many CTO PCI have been performed during 2020 in your center?*

How many CTO PCI did you personally perform during 2020 ?

How many CTO PCI do you consider performing this year?

How have you heard about the ML CTO Course?*

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

Personal data*

By sending this form, I agree that my personal data might be used for the purposes of my logistic arrangements by the company or any service providers that may need it.

Phone

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MLCTO 2021 – REGISTRATION FOR A DIGITAL PARTICIPATION