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2019 ADEG Workshop Registration Form

Name to appear on Cert of Attendance*

:

 

MCR No* :

GP Other (Please specify specialty)
Clinic Name* :
Address* :
Contact Phone : Clinic : Hp* : Fax :
Email* :
Payment by* :

Visa   Master   Cheque no : 

Bank Name* :
Card No** :

- - -

CVC No** :

Exp Date (mm/yy)**

/

Name on Card** :
 
I wish to register for the following workshop (pls tick)* :
08.03.20 : 8.30am – 12.30pm : Lasers and IPL Hair Removal
08.03.20 : 1.30pm – 5.30pm : Chemical Peels
26.04.20 : 8:30 am - 12.30pm : Body Contouring
26.04.20 : 1.30pm – 5.30pm : Non surgical skin tightening
31.05.20 : 8.30pm – 12.30pm : Botulinum Toxin A
31.05.20 : 1.30pm – 5.30pm : Dermal Fillers
28.06.20 : 8.30am – 12.30pm : Pigment Lasers
28.06.20 : 1.30pm – 5.30pm : Intense Pulsed Light
26.07.20 : 8.30am – 12.30pm : Ablative Lasers
26.07.20 : 1.30pm – 5.30pm : Fractional Lasers
 
Not registering , put me on your e-mailing list
Comment :
*   : Mandatory field
** : Mandatory field when Visa or Master selected.
Please check your entries before submitting your form.

 

Venue of Workshop : Tentatively Lecture Room , National Skin Centre (venue subject to change).


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