Application for CSI 360° Hands-on training course on LAA closure

1. Personal information

Question Title

* Title

Mrs

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* Contact details

Full name *

Instution *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

Question Title

* Date of birth (DD/MM/YYYY)

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* Speciality

Please specify if you selected "Other"

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* Experience in interventional cardiology (please indicate the year you began your practice in the field)

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* How many LAA cases do you perform on average in a year?

Less than 10 cases performed in a year

10 - 40 cases performed in a year

Over 40 cases performed in a year

Question Title

* What kind of imaging do you use for LAA procedures?

Question Title

* What kind of sedation do you use for LAA procedures?

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* Main place of work

Name of institution

Type of institution

Department

Address

Address 2

Postal/Zip code

City

Country

Application for CSI 360° Hands-on training course on LAA closure

1. Personal information

Question Title

* Title

Question Title

* Contact details

Question Title

* Date of birth (DD/MM/YYYY)

Question Title

* Speciality

Question Title

* Experience in interventional cardiology (please indicate the year you began your practice in the field)

Question Title

* How many LAA cases do you perform on average in a year?

Question Title

* What kind of imaging do you use for LAA procedures?

Question Title

* What kind of sedation do you use for LAA procedures?

Question Title

* Main place of work

Question Title

* Professional ID number (if applicable)

Question Title

* Motivational letter (Why would you like to take part in this hands-on training?)