415 1,540 820

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