REGISTRATION FORM - PRIMA Annual Medical Congress 2019

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PRIMA Annual Medical Congress 2019 Registration Form

Email *

PRIMA Annual Medical Congress 2019

Full Name (This is the name that will appear on your Certificate) *

Membership status in PRIMA *

Member, Active

Inactive

Non-member

Home/Mailing Address *

Contact number *

E-mail address *

Primary Clinic/Office and Address

Primary Clinic/Office Contact number

Name and contact number of person to notify in case of emergency *

How did you know about this conference? *

Will you be attending the Dinner Cruise Fellowship? *

Yes (Please sign up at www.primaphil.com/sunsetcruise2019 after filling up this form.)

Do you plan to book a hotel room in the venue? *

Yes

Would you like to receive updates and announcements of PRIMA activities? *

Yes, I would like to stay updated on the activities of PRIMA

No, thanks. I would rather not know.

Notes:

*Please go to https://www.primaphil.com/congress2019 for payment guidelines to complete your registration.

*You will be considered registered only after we have received and verified your payment. You will be advised whether your registration has been successful or not.

*Special room rates are available at Edsa Shangrila Hotel for all participants. You may email reservations.esl@shangri-la.com for your room requirements. Indicate that you are booking with PRIMA to avail of our special rates.x

A copy of your responses will be emailed to the address you provided.

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