Roche DMD | GOSH 2024 | Registration Form
Title and Name (As shown on passport)
Email Address
Mobile/Cell Phone number?
Institution/Hospital?
What is your job title/speciality?
Is there any other information we should be aware of?
How many DMD patients do you have?
Are there any particular areas or topics of interest that you would like us to potentially cover in the program?
Would you be interested in submitting a patient case study to potentially be discussed with Professor Mercuri and the team? (If you select yes, you are consenting for us to contact you with further details regarding the case study)
As this event is being recorded do you give permission to be on camera?
Country
Select one...
Special requirements? (Including dietary requirements)
Yes
No
Gender
Male
Female
Other
Photo
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Privacy Policy
.
Thank you! Your submission has been received!
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