Diabetes2012 Register

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GRADUATE INSTITUTE of OPTOMETRY| Postgraduate Education for Optometrists

Programme Details

REGISTRATION FORM
Diabetes – Comprehensive Patient Care for the Primary Optometrist - NECO

Registration date: 3 February 2012

You may either:

Print this form, complete it and fax it to us or,
Complete the form below and click on the submit button to complete your registration

Diabetes - Comprehensive patient care for the primary optometrist

PLEASE COMPLETE THE FOLLOWING REQUESTED INFORMATION AND FAX OR EMAIL IT TOGETHER WITH CONFIRMATION OF PAYMENT TO THE GRADUATE INSTITUTE OF OPTOMETRY

PLEASE TYPE IN CAPITAL LETTERS

FULL NAME
________________________(LAST - FAMILY NAME)____________________________

First Names:
_____________(FIRST - GIVEN NAME)___________________(MIDDLE NAME)______

Date of Birth:
_______________(MONTH)_____________(DAY)_____________________(YEAR)

SEX:
__________(MALE)____________________________(FEMALE)__________________

COUNTRY OF CITIZENSHIP:

HPCSA Registration Number:

Identification Number (If not a South African citizen please give PASSPORT identification number)

Contact Mailing Address:

Street Address/Box Number:

City:

Province:

Code:

Country:

Phone number:

Fax Number:

Cell Phone:

Email Address:

NAME TO APPEAR ON GRADUATION CERTIFICATE: __

JOHANNESBURG ONLY: 14 - 18 March 2012 Constantia Hotel and Conference Centre, Midrand, Johannesburg
Commencing Wed 14th March 14h00

Labs: Delegates will be divided into groups of 25 for the 4 hour labs

INSUFFICIENT DELEGATE NUMBERS WILL LEAD TO THE POSTPONEMENT OR EVENTUAL CANCELLATION OF A PARTICULAR COURSE.

AT ANY TIME DURING THE COURSE, IF YOUR E-MAIL ADDRESS CHANGES OR YOU WISH TO WITHDRAW FROM THE COURSE, PLEASE INFORM THE GRADUATE INSTITUTE OF OPTOMETRY AS SOON AS POSSIBLE.

Refunds

Fees will be fully refundable in the case where a course is cancelled. Withdrawal from a course or module will, however, not result in a full refund. Request will be submitted to the course directors for consideration.

Examination date: To be confirmed

Remake Examinations

THERE WILL BE NO REMAKE EXAMINATIONS FOR THIS COURSE AS PER NECO POLICY

DIABETES – COMPREHENSIVE PATIENT CARE FOR THE PRIMARY OPTOMETRIST
Parts 1 – 4

CPD

Lecture Dates & Times
14 – 18 March 2012

Course Instructor

Site

Cost

Select site

30 CPD points

Wed14th   14h00 – 18h00
Thurs 15th   09h00 – 17h30
Fri 16th           09h00 – 17h30
Sat 17th         08h00 – 16h00
Sun 18th        08h00 – 16h00
Inclusive of 4 hours of labs -
25 delegates per group

Dr David Shein (USA)
Dr Cavallerano
( USA)
Joan Hill (USA)

Johannesburg only
Constantia Hotel & Conference Centre, Midrand, Johannesburg

R4995.00
incl. VAT

COST

AMOUNT DUE

CLOSING DATE

R4995.00 incl VAT
Certification & CPD

Due with registration
by 3 February 2012

3 February 2012

Confirmation of registration will be sent out after the closing date.

Direct Deposits:
(Cash or cheque Only)

ABSA Bank
Account. Holder: Investec Private Bank - The Graduate Institute of Optometry
Account Number: 01043960306
Reference number: 10010646107
Branch Code: 632005

Internet Banking:

Investec Private Bank
Account Holder: The Graduate Institute of Optometry
Account number: 10010646107
Branch Code: 580105

Confirmation of payments must be faxed to 043 7484901 or e-mailed to fiona@gio.co.za with your name clearly reflected. No facilities are available for credit card payments.

Signature

Date

Stef Kriel Dip. Optom. M.HPE CAS