Registration Form MSUS Comprehensive Course 19-20 February, Brussels

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Dear,

Thank you for your interest in our course. Would you like to participate?
Please fill in the form below!

First Name *

Surname *

Specialism *

Radiologist

Physical Medicine

Sports physician

Other:

Hospital/Practice *

RIZIV number (for accreditation points) *

Billing Address

In the following section we ask you to please enter the address to which we should send the invoice. This can be the address of your private practice or the hospital where you work.

Billing name - Company name *

Street + number *

Postal code + city *

Company number (or VAT number) *

E-mail address *

Phone number *

I agree that Benetec BV uses my details to send me information about future courses, congresses and new products. *

Yes

Thank you for your registration!
You will receive an e-mail in the course of this week with our confirmation of receipt. Do you have any questions in the meantime? Feel free to send an e-mail to courses@benetecmed.com.

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