Harvard Medical School Dubai Center

HMSDC Online Registration Form

Practi-Med: Critical Care
October 31 - November 1, 2008
Grand Hyatt Hotel
Dubai, The United Arab Emirates

Please complete this secure form to register online.

*First Name:

*Last Name:

*Degree:

Note: The name above will be used on the certificate of attendance.

Occupation:

Please check all of the items below that describe your occupation.

	Internal Medicine
	Emergency Medicine
	Cardiovascular Disease
	Critical Care Medicine
	Anesthesiology
	Surgical Critical Care
	General Medicine
	Medical Students
	Nurses
	Other (please specify):

*Title:

Principal Specialty:

*Organization:

*Address:

P. O. Box:

*City:

Province or State:

Postal Code:

*Country:

*Telephone:

Fax Number :

*Email:

How did you hear about the course?

*Have you previously participated in HMSDC programs?	YesNo
I would like to receive periodic email updates from HMSDC.

Registration Fees

Registration fees are USD $410 (AED 1500).

All CME programs offered by HMSDC are fully accredited. Please refer to the specific program materials for the details of the accreditation designated to the course(s) for which you are registering.

Please read the following terms and conditions
and confirm your acceptance of them below.

I agree with the terms and conditions as outlined.

I DO NOT agree with the terms and conditions as outlined.

Note: Fees for this course will be payable directly to Dubai Healthcare City via Mashreqbank.

If you have a Sponsoring Organization Code, please enter it here: