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CKRT REGISTRATION FORM
Renal and Multiorgan Support in Critically ill patients
Name
*
First/Given Name
Last/Surname
Email
*
Country/Region
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Department
*
Phone Number
*
MCR/SNB Reg number
For Singapore registered Doctors and Nurses Only. Please type NA if not applicable
Organization
*
Job Title
*
I have a professional interest in attending the event because
*
Do you have any experience in CKRT Therapy?
*
Yes
No
Other
Do you have any experience in CKRT Therapy - Khác
*
Type of organisation
*
Privately Owned
Publicly Owned / Funded
Self-Employed
DISCLAIMER
By agreeing to this, the following points are acknowledged : I have not agreed to attend the Event as an inducement or reward for providing the Company with any referrals, prescriptions, business transaction, opportunity, approval or concession. To the best of my knowledge, my attendance at the Event does not violate any laws or regulations of my country of residence and/or employment, or any policy or rule of my employer. I agree to treat my participation in the event and the costs correctly for tax purposes. I understand that the Company will not pay for my costs and will not bear any expense in connection with my attendance at the Event except for meals. I understand that FME shall retain the right to keep a copy of this certification for business purposes. I agree to promptly notify the Company if, prior to the event, there are any subsequent developments or any circumstances that may have an impact on or change any information provided here or cause this certification to be inaccurate or incomplete. By registering for this symposium, I confirm that I have obtained my employer’s approval and notified my employer, if required, prior to attending the symposium.
*
By agreeing to this, the following points are acknowledged :
I have not agreed to attend the Event as an inducement or reward for providing the Company with any referrals, prescriptions, business transaction, opportunity, approval or concession.
To the best of my knowledge, my attendance at the Event does not violate any laws or regulations of my country of residence and/or employment, or any policy or rule of my employer.
I agree to treat my participation in the event and the costs correctly for tax purposes.
I understand that the Company will not pay for my costs and will not bear any expense in connection with my attendance at the Event except for meals.
I understand that FME shall retain the right to keep a copy of this certification for business purposes.
I agree to promptly notify the Company if, prior to the event, there are any subsequent developments or any circumstances that may have an impact on or change any information provided here or cause this certification to be inaccurate or incomplete.
By registering for this symposium, I confirm that I have obtained my employer’s approval and notified my employer, if required, prior to attending the symposium.
I Agree to the above disclaimer
PRIVACY NOTICE
I agree that the Personal Data I provide will be governed by Fresenius Medical Care's Privacy Policy [ https://www.freseniusmedicalcare.sg/en-sg/privacy-policy]. By participating in this event, I provide consent to Fresenius Medical Care Singapore for the video and audio recording of the digital discussion, and provide consent to Fresenius Medical Care Singapore to retain, release, disseminate and reproduce the recordings, in parts or in full, at Fresenius Medical Care Singapore’s sole decision and discretion.
*
I agree that the Personal Data I provide will be governed by Fresenius Medical Care's Privacy Policy [
https://www.freseniusmedicalcare.sg/en-sg/privacy-policy
].
By participating in this event, I provide consent to Fresenius Medical Care Singapore for the video and audio recording of the digital discussion, and provide consent to Fresenius Medical Care Singapore to retain, release, disseminate and reproduce the recordings, in parts or in full, at Fresenius Medical Care Singapore’s sole decision and discretion.
I Agree to the above Privacy Notice
PRIVACY NOTICE
I agree to receive information from Fresenius Medical Care Singapore via email, postal mail, SMS, telephone, etc about our products, services and events.
Check Privacy
*
I Agree to the above Privacy Notice
I Disagree to the above Privacy Notice
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