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Application for CSI 360° Hands-on training course on LAA closure
5.
Personal information
*
Title
(Required.)
Dr
Pr
Mr
Mrs
Ms
*
Contact details
(Required.)
Full name
*
Instution
*
Address
*
Address 2
City/Town
*
State/Province
*
ZIP/Postal Code
*
Country
*
Email Address
*
Phone Number
*
*
Date of birth (DD/MM/YYYY)
(Required.)
*
Speciality
(Required.)
Interventional cardiologist
Electrophysiologist
Imaging specialist
Surgeon
Other
Please specify if you selected "Other"
*
Experience in interventional cardiology (please indicate the year you began your practice in the field)
(Required.)
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Prior 1970
*
How many LAA cases do you perform on average in a year?
(Required.)
Less than 10 cases performed in a year
10 - 40 cases performed in a year
Over 40 cases performed in a year
*
What kind of imaging do you use for LAA procedures?
(Required.)
*
What kind of sedation do you use for LAA procedures?
(Required.)
*
Main place of work
(Required.)
Name of institution
Type of institution
Department
Address
Address 2
Postal/Zip code
City
Country
Professional ID number (if applicable)
*
Motivational letter (Why would you like to take part in this hands-on training?)
(Required.)
