Please enable JavaScript in your browser to complete this form.Forename *Surname *Title *TitleMrMissDrMrsMDMsOtherOther- TitlePlease SpecifySelect Appropriate Level or mention if other (copy) *Select Appropriate Level or mention if other* OtherSpRFT/CTSASConsultantST 1-3ST 4-6ST 7-8SFOFoundation DoctorCTOther- GradePlease SpecifySpecialty *Specialty*Other ENT Neurosurgery Opthalmology Maxillofacial surgeryPlastic SurgeryDermatologyAddress *Postcode *Contact Number* *Please select country codeEmergency Contact Name *Emergency Phone Number *Please select country codeEmail *Registration Fee: *1. Wessex Rhinoplasty Dissection Course (Sun 17/06/2027) - £4502. Wessex Facial Plastic Surgery Flap Reconstruction Dissection Course (Mon 18/06/2027) - £450 3. Both Courses Together - £800 I wish to attend the 9th Wessex Facial Plastic Surgery Course 2027 (Registration fee includes tea/coffee and lunch on the course days)Please tick any one as appropriate. *I consent to share my “name and city only” with the event supporters. I consent to share my “name, city and email” with the event supporters. I do not consent to share any of my details with the event supporters. Cancellation policy for all new registrations :- By 28/02/2027 - Full Refund minus admin charge of £40. By 31/03/2027 – 50% refund. After 31/03/2027 – No refund at all (for all reasons including health, visa refusal etc) unless you bring a full paying replacement delegate. Please have relevant travel/health insurance in place to cover your cancellation costs if any. Receipt of payment guarantees place. Special Needs- Access *Special Needs-Dietary Requirements *Name & Course *Payments should be made as a balance transfer: Account Name: Surgimed Academy Limited Account number: 94556828 Sort Code: 60-83-71 Bank: Starling Bank SWIFT/BIC: SRLGGB2L IBAN: GB19SRLG60837194556828 Disclaimer - Please put your Name and Wessex ENT Courses as reference. The signed form can be scanned and emailed to the below email address.DatePlease prove you are human by selecting the key:Submit
