Registration Form Pain by srH59X9

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									                                                                Kingdom of Saudi Arabia
                                                              National Guard Health Affairs
                                                  King Saud bin Abdulaziz University for Health Sciences


                      1st NGHA Conference on Pain Management &
                    2nd Meeting of the Saudi Society of Pain Medicine
              - 11 October
Registration 9Form 2012, KSAU-HS Convention Centre
PLEASE TYPE OR PRINT YOUR NAME CLEARLY AS YOU WANT IT TO APPEAR ON YOUR CERTIFICATE OF
ATTENDANCE AND RETURN THIS FORM WITH PAYMENT.
TITLE:         Physician/Resident                Non-physician              Others:
GENDER:          Male               Female



         First Name                                           Middle Name                                     Family Name


         Profession/Specialty                        Saudi Council Professional No.                             Institution


    Telephone No. (Including Information Dialing Code)                                              Mobile No


                             Fax No.                                                                Email Address


                                       Mailing Address (City with postal code/country)

                                             CONFERENCE : 9-11 October 2012
                                                        Free Registration
                                               Limited seats. First come, first serve.

                                         WORKSHOPS
      Pls. note: Cadaver Workshop needs prior approval before payment of registration fee.
        9 October 2012                 10 October 2012                   11 October 2012
14:00-16:00 at KSAU-HS Conv Ctr 14:00-16:00 at KSAU-HS Conv Ctr  14:00-16:00 at KSAU-HS Conv Ctr
          Cadaver Workshop 1                              Cadaver Workshop 3                                Cadaver Workshop 6
           Venue: COM Anatomy Lab                             Venue: COM Anatomy Lab                          Venue: COM Anatomy Lab
      Cadaveric hands-on workshop on                  Cadaveric hands-on workshop on                    Cadaveric hands-on workshop on
       interventional pain techniques                  interventional pain techniques                    interventional pain techniques
            (Neuroaxial Blocks &                           (Head & Neck Blocks)                              ( Sympathetic Blocks)
             Neuromodulation )                                Registration: SR 1,000                        Registration: SR 1,000
          Registration: SR 1,000
                Workshop 2                                        Workshop 4                                      Workshop 7
              Ultrasound-guided                          Neuromodulation techniques                       Non-invasive therapeutic pain
        interventional pain techniques                         on manikins                                        techniques
           Registration: SR 400                               Registration: SR 400                           Registration: SR 400

                                                                 Workshop 5                                       Workshop 8
                                                                  Acupuncture                           Practical Management/Strategies
                                                              Registration: SR 600                            for Challenging Cases
                                                                                                             Registration: SR 400
Important Information:
1. Workshops Registration is not confirmed until payment is        4. Send payment and registration form or copy of your deposit slip to:
   received and with prior approval.                                  Symposia & Conferences Division, Postgraduate Education and
2. Payment is accepted in cash and bank transfer.                     Academic Affairs Deanship, NGHA,
3. Deposit registration fee to:                                        P.O. Box 22490, Riyadh 11426, Saudi Arabia,
   Account Name: ESC/Academic Affairs                                  Tel. No. +966 1 801-1111 ext. nos. 48459/48461
   Account No. 01-08-00520891-009-1                                    Fax: +966 1 2520040, Email: accaff1_symposia@ngha.med.sa
   IBAN: SA653040-01-08-00520891-009-1                             5. Cancellation/Refund Policy: Request for refund must be received one
   Bank: Arab National Bank                                           week prior to the conference. Administrative fee of SR50 or 20% of the
   Branch: Khashmalaan                                                total registration fee (whichever is greater) will be deducted from all
                                                                      refunds.

Please visit the event’s website: http://www.managepainconf.net

								
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