Echo-Medanta 2012

A comprehensive teaching course on echocardiography

6th-8th September, 2012

Registration form
Name: ___________________________________________ Age:_______ Years

Gender: M/F

Medical Qualifications:_____________________________________________________________________________
Address:

___________________________________________________________
___________________________________________________________
___________________________________________________________
City_____________________, State___________________________
Pin Code________________

Email: _____________________________________________

Phone/Mob:_________________________________

What type of set-up are you working for?

Medical College

Non-teaching Govt. Hospital

Large Pvt. Hospital

Nursing Home

Your Own Clinic

Already performing echocardiography? ______________(Yes/No), If yes, what duration?__________

Any formal training?___________________________________________________________________________________
Membership of any professional organization?
Indian Academy of Echocardiography (IAE)

Cardiological Society of India (CSI)

Association of Physicians of India (API)

Other___________________________________

Enclosed is the Cheque/DD no _____________________, of Rs 5000/-, bank name and

branch______________________________________________________, dated ________________________payable at
New Delhi, in favor of Global Health Private Limited.
Mail this form at:

For enquiries contact:

Ms Sarlla Shakya +91-8800494247
Ms Archana Mirgan +91-9971698197
Email: rrkasliwal@hotmail.com

Dr. Ravi R Kasliwal

Room no. 9, 3rd floor,
Medanta - The Medicity,
Sector 38, Gurgaon,
Haryana 122001, INDIA.