Please enable JavaScript in your browser to complete this form.Forename *Surname* *Title *TitleMrMissDrMrsMDMsOtherOther- TitlePlease SpecifyTick Appropriate Level or mention if other *Select Appropriate Level or mention if other* OtherSpR( 4, 5, 6 )SASConsultantST 1-3ST 4-6ST 7-8SFOFoundation DoctorCTOther- GradePlease SpecifySpecialty *Specialty*OtherENTNeurosurgeryOpthalmology Maxillofacial surgeryPlastic SurgeryDermatologyRight/Left-Handed *Right/Left-Handed*Right-HandedLeft-HandedAddress *Postcode *Contact Number* *Please select country codeEmergency Contact Name *Emergency Phone Number *Please select country codeEmail *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 contact with the event supporters.I do not consent to share any of my details with the event supporters.I wish to attend the 20th Wessex Advanced Sinus Surgery Course 2027 Registration Fee: Dissector Early Bird Fee - £1,595 Dissector Fee - £1,695 (Registration fee includes tea/coffee and lunch on the course days) Cancellation policy for all new registrations :- By 28/02/2027 - Full Refund minus admin charge of £50. 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. Special Needs- Access Needs *Special Needs- Dietary Requirements *Receipt of payment guarantees place. *Payments should be made as a balance transfer: Account Name: Wessex Endosurgical Academy Limited Account number: 94650796 Sort Code: 23-08-01 Bank: Wise Payments Limited SWIFT/BIC: TRWIGB2LXXX IBAN: GB61 TRWI 2308 0194 6507 96 Disclaimer - Please put your Name & Course as reference. The signed form can be scanned and emailed to the below email address. Date Please prove you are human by selecting the heart:Submit
