CONTINUING MEDICAL EDUCATION
REGISTRATION FORM
Activity: Certified Professional in Healthcare Risk Management
(CPHRM)
First Name:
Last Name:
Primary Phone Number:
Date:
☐ Dr.
☐ Mr.
☐ Mrs.
☐ Ms.
Gender: ☐ M ☐ F
Secondary Phone number:
Primary Email:
Secondary Email:
☐ Add me to Mailing List
Street:
Building:
City:
Country:
Occupation:*
☐ Dentist ☐ Dietician ☐ Fellow ☐ Intern ☐ Nurse ☐ Orthodontist ☐ Para Medical ☐ Pharmacist
☐ Physician ☐ Resident ☐ Student ☐ Other, please specify:
Hospital(s):
Specialty:*
☐ Alternative Medicine
☐ Anesthesiology
☐ Biochemistry
☐ Cardiology
☐ Clinical Pharmacology
☐ Dentist
☐ Dermatology
☐ Emergency Medicine
☐ Endocrinology
☐ Family Medicine
☐ Gastroenterology
☐ General Medicine
☐ Genetics
☐ Geriatrics
☐ Hematology
☐ Infectious Disease
☐ Internal Medicine
☐ Legal/Ethics
☐ Miscellaneous
☐ Nephrology
☐ Neurology
☐ Nursing
☐ Nutrition
☐ Obstetrics/Gynecology
☐ Oncology
☐ Ophthalmology
☐ Orthopedics
☐ Otolaryngology
☐ Pain Management
☐ Pathology
☐ Pediatrics
☐ Plastic Surgery
☐ Psychiatry
☐ Radiology/Imaging
☐ Respirology
☐ Rheumatology
☐ Rural Medicine
☐ Rural Medicine
☐ Sports Medicine
☐ Surgery
☐ Urology
☐ Other, please specify:
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Society:*
☐ Lebanese Order of Physicians - Beirut
☐ Lebanese Order of Physicians – Tripoli
☐ Lebanese Order of Nurses
Order registration number (‫)رقم النقابة‬:*
Please note that the (*) represents an obligatory field.
☐ Lebanese Order of Dentists
☐ Lebanese Order of Pharmacists
☐ Other, please specify:
Continuing Medical Education office Registration Policies:
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Pre-registration is encouraged for all events.
Applicable registration fees should be paid at least 3 days before the event to reserve your place.
If you choose to pay on-site you are kindly requested to confirm your attendance by email or phone.
Canceled or postponed events will be announced on the web site as quickly as possible, and all
registrants will be notified of the changes provided they have included their email or phone number in the
online registration form.
Events with Limited Places:
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Registration will close when the event fills to capacity.
Unpaid pre-registration for these events will be held until the scheduled event start time. After that time,
registrants on waiting list will be given available seats.
On–site registration for these events is on “first come, first served” basis and is subject to space
availability.
Refund Policy:
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Registration cancellation and refund requests must be made in writing and sent via email to
cmeoffice@aub.edu.lb .
Registration fees are refundable up to two days prior to the event after which no refunds will be
granted.
Registrants who paid for a postponed or canceled event can either:
- Cancel their registration and receive a full refund of the registration fee.
- Apply their registration payment to another event, or
- Attend the event if it is rescheduled.
Thank you for registering for our activity.
American University of Beirut
Continuing Medical Education Office0
T: 01-350000 ext.4879-4718
F: 01-744467
E:
cmeoffice@aub.edu.lb
cme@aub.edu.lb
W:
http://cme.aub.edu.lb
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