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Registration Form
Neurological Imaging with Dynamic Volume CT
Brain Perfusion and 4D CTA
Leiden, The Netherlands, March 21-22, 2019
Title:
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Mr
Mrs
MD
MD PhD
MSc
PhD
Family Name:
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First Name:
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Hospital or Institution:
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Department:
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Address:
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Zip Code:
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City:
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Country:
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Phone:
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Mobile:[mobile_]
FAX:
E-mail:
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Speciality:
Previous experience neurological imaging?
Yes
No
Previous experience with CT perfusion?
Yes
No
Previous experience with 4D CTA?
Yes
No
Are you a Canon user?
Yes
No
Registration Luncheons (lunches buffet)
Thursday, March 21, 2019:
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Yes
No
Friday, March 22, 2019:
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Yes
No
Diet restrictions? Please specify:
Accommodation
Yes, I wish to be accommodated at 3* Tulip Inn Leiden Centre at € 93.00 pppn incl. breakfast, excl. city tax at € 2,50 pp (2018 rate)
Yes, I wish to be accommodated at 3* IBIS Leiden Centre at € 83.00 pppn incl. breakfast, excl. city tax at € 2,50 pp (2018 rate)
No thank you, I will arrange my own accommodation
Night of Wednesday, 20 March, 2019
Night of Thursday, 21 March, 2019
Night of Friday, 22 March, 2019
Yes thank you, I accept the invitation to the dinner, Thursday March 21, 2019
No thank you, I decline the invitation to the dinner, Thursday March 21, 2019
M.A.A. van Walderveen, MD, PhD, Neurointerventionalist-neuroradiologist
A. Meijer, MD, PhD, Neuroradiologist at Radboud UMC
Organizers Neurological Imaging with Dynamic Volume CT:
Brain perfusion and 4D CTA
tel.: +31 715264376 / fax: +31 71 5248256
www.lumc.nl/org/radiologie/onderwijs/BijEnNascholing/
After sending this form, you will receive an email from us shortly with a link, in order to confirm and finalize your registration.
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