Trabectome Training Registration

Select	Training Session	Agenda	Location	Trainer	Availability
	Select this to indicate that you are only interested in receiving future training annoucements at this time		Tustin, CA	TBD	OPEN

NOTE: We are arranging more Trabectome Training/Wet Lab opportunities this year (2018), please contact us at the NeoMedix office for the future dates and locations. training@neomedix.net We may have one coming to your region very soon. Thank you!

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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