micro-surgical management of adult & infantile glaucoma - Trabectome - Training

Trabectome Training Registration

STEP 1 - SELECT YOUR PREFERRED TRAINING SESSIONS

Please select your preferred training session.

Training Session	Agenda	Location	Trainer	Availability
Trabectome skill transfer - 1 Day Prior to AAO - Friday October 14, 2016 - Rush University Medical Center	View	Chicago, IL	Dr. Madhu Gorla, MD	OPEN
Trabectome skill transfer - Neomedix Corporation - Sunday October 16 - 17, 2016		Tustin, CA	Dr.Minckler/Baerveldt	CLOSED
Trabectome skill transfer - Neomedix Corporation - Sunday November 20 - 21, 2016	View	Tustin, CA	Dr.Minckler/Baerveldt	OPEN
Trabectome skill transfer - Neomedix Corporation - Sunday December 18 - 19, 2016	View	Tustin, CA	Dr.Minckler/Baerveldt	OPEN
Trabectome skill transfer - ARVO 2017 Tuesday May 9, 2017 at 17:00 to 18:30. Baltimore Convention Center		Baltimore, Maryland	Dr Friedman	OPEN
Select this to indicate that you are only interested in receiving future training annoucements at this time		Tustin, CA	TBD	OPEN

STEP 2 - TRAINEE DETAILS

*I am a:

Doctor Patient Distributor Other

*Operate From

Hospital ASC Both Hospital and ASC

*First Name

*Last Name

*Credentials

*Company

*Job Title

*Address Line 1

Address Line 2

*City

*State/Province

*Zip Code

*Country

*Phone Number

*Fax Number

*E-mail Address

*Questions or Comments

*Invited To Training By:

*Attachments

Please note that to participate in the surgical observation portion of the Trabectome training program, the surgical facility requires your current PPD and CV submitted. Please attach the required documents using the form below.

Resume (CV):

PPD Test Result:

Please specify the mailing address where you would like your training certificate to be mailed to.

Mailing address is the same

*Address Line 1

*Type

Address Line 2

*City

*State/Province

*Zip Code

*Country

Hospital Details

*Hospital Name

*Address Line 1

Address Line 2

*City

*State/Province

*Zip Code

*Country

*Phone Number

Fax Number

Website

Hospital Operating Room Head Nurse

*First Name

*Last Name

*E-mail Address

*Phone Number

Fax Number

Hospital Administrator

*First Name

*Last Name

*E-mail Address

*Phone Number

Fax Number

ASC Details

*ASC Name

*Address Line 1

Address Line 2

*City

*State/Province

*Zip Code

*Country

*Phone Number

Fax Number

Website

ASC Operating Room Head Nurse

*First Name

*Last Name

*E-mail Address

*Phone Number

Fax Number

ASC Administrator

*First Name

*Last Name

*E-mail Address

*Phone Number

Fax Number

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