UNIVERSITY OF CAPE TOWN
Department of Obstetrics & Gynaecology

POSTGRADUATE REFRESHER COURSE
26 - 28 November 2015
Double Tree by Hilton Hotel Cape Town, Upper Eastside

REGISTRATION FORM

To register, kindly complete one form per delegate.

SECTION 1: Delegate Information

Title: Last Name:
First Name
(for badge):
MP Number:
Institution Name: Institution Vat Number:
This is my: Private Address / Institution Address
Address: City:
State/Province: ZIP/Post Code:
Country:
Telephone:
(Country code/city code/number)
Fax:
(Country code/city code/number)
E-Mail: Mobile/Cell Number:
Please advise if you would like to include your name and email address to the delegate pack: Yes /No
Registration Code: For office use only
Please advise if you require transport to UCT: Yes /No
Dietary Preferences
Vegetarian: Yes /No /Other If other, specify:

REGISTRATION FEES: Refresher Course

26 - 28 November 2015
Double Tree by Hilton Hotel Cape Town, Upper Eastside

Registration Fees - South African Rand (ZAR) Only (includes VAT)

Registration Category
Early
Before
23 Aug 2015
Standard
After
23 Aug 2015
Onsite
No. of
Persons
Amount
(ZAR)
Specialists
R2 450
R2 800
R2 950
Registrars, Physiotherapists, Nurses & other Health Professionals
R1 100
R1 200
R1 400
Retired Member Delegate Registration
70 & over only
R1 100
R1 200
R1 400
Daily Fee: Specialists
Please select day attending
26 Nov 2015 (Thu)
R1 400
 
27 Nov 2015 (Fri)
R1 400
 
28 Nov 2015 (Sat)
R1 400
Daily Fee: Registrars, Physiotherapists, Nurses & other Health Professionals
Please select day attending
26 Nov 2015 (Thu)
R650
 
27 Nov 2015 (Fri)
R650
 
28 Nov 2015 (Sat)
R650
TOTAL: Registration Fees - Refresher Course

WORKSHOPS - Please choose only one workshop per day. Indicate 1st, 2nd and 3rd choice in appropriate box.

Thursday, 26 November 2015 Friday, 27 November 2015
1.
Hysteroscopy Masterclass (20 max)
Fully Booked
1.
Gynae-oncology Masterclass: Colposcopy and Vulval Disorders
2.
Cutting-Edge Obstetrics
2.
Gynaecology USS (12 max)
Fully Booked
3.
Medico-legal Workshop
3.
Laparoscopic Suturing - intro (20 max)
Fully Booked
4.
Surgical Complications
4.
Challenges in Reproductive Medicine
5.
Practical Encounters in Fertility Management
5.
Challenges in Prenatal Diagnosis

REGISTRATION FEES: UCT Live Surgery Workshop

24 - 25 November 2015
UCT Early Learning Centre, UCT

Dynamic lecture programme will include live transmission of surgical procedures by visiting surgeons Dr. Shailesh Puntambekar, Dr. Ivo Meinhold-Heerlein, Dr. Rafique Parkar and the local faculty. Preference will be given to delegates attending the Refresher Course.

Registration Category
Early
Before
23 Aug 2015
Standard
After
23 Aug 2015
Onsite
No. of
Persons
Amount
(ZAR)
Specialists
R2 450
R2 800
R2 950
Registrars, Physiotherapists, Nurses & other Health Professionals
R1 100
R1 200
R1 400
Daily Fee: Specialists
Please select day attending
24 Nov 2015 (Tue)
R1 390
25 Nov 2015 (Wed)
R1 390
Daily Fee: Registrars, Physiotherapists, Nurses & other Health Professionals
Please select day attending
24 Nov 2015 (Tue)
R850
25 Nov 2015 (Wed)
R850
TOTAL: Registration Fees - Pre Conference Workshop On Endoscopy

REGISTRATION FEES: Combined UCT Live Surgery Workshop and Refresher Course

A special discounted registration fee applies to specialists and registrars who attend both the pre-congress workshop and the refresher course, provided they register before 23 August 2015.

Registration Category
Early
Before 23 August 2015
Standard
After 23 August 2015
Onsite
No. of
Persons
Amount
(ZAR)
Specialists
R3 850
R4 050
R4 350
Registrars, Physiotherapists, Nurses & other Health Professionals
R1 450
R1 650
R1 815
TOTAL: Registration Fees - Combined Pre Conference Endoscopy Workshop & Refresher Course

TOTAL: Registration Fees

Registration fees Include: Attendance at all sessions, light lunch, tea and coffee breaks, bag and entry to the Exhibition.

Cancellation Fees: Please notify the Secretariat in writing of any cancellations, all approved refunds will be issued after the course. An administration fee of 10% will be charged for all cancellations received before 23 September 2015. Please note that no refunds can be made for cancellations made after 23 September 2015.

PAYMENT DETAILS

Please select your payment option below.

Option 1
Bank Transfer
You must specify your name and the words "O&G Refresher Course" on your bank transfer. Forward to:
Account Name:Turners Conferences & Convention Pty Ltd
Bank:ABSA Bank
Account No.:4060455419
Branch:KZN Business Banking
Branch Code:632005
Swift No.:ABSA-ZA-JJ
(Please fax a copy of your transfer to Turners Conferences +27 31 368 6623)
Final date for Bank Transfer payments will be the 13th November 2015.
Option 2
Credit Card
Please complete the following authorisation for Congress Organisers to debit your credit card.
A clear photocopy of both sides of the credit card is required for bank approval and verification

I, the undersigned, do hereby authorise Turners Conferences to debit my credit card for the following amounts: (please fax a copy of the front and back of your credit card to Turners)

Credit Card Type:
Credit Card Number
Expiry Date
Cardholder's Name
3 Digit no. on reverse side where applicable

All transactions are conducted in terms of Turners standard conditions of trading. They are published on the Turners website & available on application.
Without the complete documents, we are unable to process your booking.

Your registration will only be confirmed once payment has been received.

Type this number into the box alongside: