Request for a grant support

Family name*

First name*

E-mail address*

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*

EVALUATION

Have you submitted an abstract into our platform?*

Yes
No

TITLE OF THE ABSTRACT*

What is your professional activity/position?*

Physician/Resident
Physician/Attending
Physician/Chief of department
Biologist
Nurse

Where do you hold your primary professional activity?*

Private non-teaching institution
Private teaching institution
Public non-teaching institution
Public teaching institution
Other

Primary professional activity center*

Which is your main field of interest?*

How would you define yourself?*

Clinician
Surgeon
Imaging expert
Fertility doctor/biologist
Basic researcher
Epidemiologist
Pain expert

PRE COURSE CONGRESS

Do you want to participate to one of the Pre-Congress Course*

Yes
No

Pre-Congress Courses*

Pre-Congress Course : AUB
Pre-Congress Course : Infertility
Pre-Congress Course : Imaging
Pre-Congress Course : Innovation

SOCIAL PROGRAM

Gala dinner*

Yes, I take part to the gala dinner
I will be accompanied by one person (78€)
No, I do not take part to the gala dinner

78€/person. 8:30 PM. Place to be confirmed.

INVOICE ADDRESS

GDPR*

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Email

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