REGISTRATION FORM Title: Prof. Dr. (Please write name in BLOCK letters) Note: The name provided below will be on the Certificate of Attendance Contact Name Organisation Designation Address City Tel Fax P.O. Box Country Mobile E-mail Registration March 31, 2015 April 1, 2015 US$ 415 / AED 1,540 US$ 465 / AED 1,720 US$ 820 / AED 3,030 US$ 905 / AED 3,350 Lecture & Video Demonstration with Moderator Skin Fillers & Botox US$ 335 / AED 1,240 US$ 390 / AED 1,540 US$ 415 / AED 1,540 US$ 685 / AED 2,530 p Conference ( 7-9 April 2015) Early Bird Registration UNTIL December 31, 2014 Pre-Registration Select [R] your Registration (Fee includes Conference Material, Lunch Coffee Break and Accredited Certificate) UNTIL US$ 390 / AED 1,440 p Pre-Conference Course (3-6 April 2015) Dermatology & Dermatopathology Course Certificate) (Fee includes Course Material, Lunch, Coffee Break and Accredited AFTER p Workshops (8 April 2015) p Workshops (7/8 April 2015) Hands On (Limited to 10 Participants) Skin Fillers & Botox TOTAL NOTE: US$ AED US$ AED US$ AED • If VISA is required, kindly send the Visa Application Form and a Valid Passport Copy along with this form. Form can be downloaded from www.dubaiderma.com. Medical Insurance is mandatory to any person travelling to the United Arab Emirates as per the new directives issued by the Dubai Immigration Authorities. Medical Insurance costs US$20 / AED 75 as indicated in the Visa Application Form. • Registration to Dubai Derma is for the duration of the conference. This entitles conference participants access to all conference and exhibition halls. This does not guarantee the conference participants a seat at any practical workshops inside the exhibition hall. We recommend arriving early to get a seat. • The conference participants should understand that the conference speakers provide only their perspective of any new techniques and procedures; and potential risks might be possible if it is applied into clinical practice without sufficient training and/or supervision. • Children below the age of 15 will not be permitted entry to the conference and exhibition halls. • Conference Registration is a pre-requisite in workshop registration. PAYMENT can be made either by cash or credit card to: INDEX® Conferences & Exhibitions Organisation Est. PAYMENT DETAILS: p Cash p Visa p Master Card Credit Card No. Name on Card_______________________________________________________________ Authorisation Note Cancellation Policy MONTH YEAR Please debit my credit card with an amount of AED...................... I, ......................................................................................... the card holder will honor this transaction and not hold INDEX® Conferences & Exhibitions Organisation Est. responsible if the credit card number has been compromised. I understand that the above mentioned charges per registration will be non-refundable Date............................................................... Contact us: Expiry Date Signature............................................................................ INDEX® Conferences & Exhibitions Organisation Est. Dubai Healthcare City, Ibn Sina Medical Complex #27, Block B, Office 203 | P.O. Box: 13636, Dubai, UAE Tel: +971 4 3624717 | Fax: +971 4 3624718 | e-mail: registration@dubaiderma.com www.dubaiderma.com