The Graduate Institute of Optometry
P O Box 2409, Beacon Bay, 5205, South Africa
36 Edly Symons Avenue, Beacon Bay, 5241, South Africa
Tel/Fax: (043) 748-4901 Mobile: 082 8296084 E-mail: iod@iafrica.com Website: www.gio.co.za
REGISTRATION FORM FOR CAS IN
ADVANCED CONTACT LENSES AND INTEGRATED ANTERIOR SEGMENT TREATMENT
AND MANAGEMENT OF OCULAR DISEASE - NECO
REGISTRATION DATE 15 JUNE 2010
PLEASE COMPLETE THE FOLLOWING REQUESTED INFORMATION AND E-MAIL OR FAX TOGETHER WITH YOUR
PROOF OF PAYMENT TO THE GRADUATE INSTITUTE OF OPTOMETRY
PLEASE TYPE OR PRINT CLEARLY IN CAPITAL LETTERS
FULL NAME :
(LAST – FAMILY NAME)
FIRST NAMES :
(FIRST – GIVEN NAME)
(MIDDLE NAME)
DATE OF BIRTH :
(MONTH)
SEX :
Circle one :
MALE
or
(DAY)
(YEAR)
FEMALE
COUNTRY OF CITIZENSHIP :
HPCSA REGISTRATION NUMBER :
IDENTIFICATION INFORMATION:
IDENTIFICATION NUMBER (13 DIGIT NUMBER) :
(If not a South African citizen please give PASSPORT identification number)
CONTACT MAILING ADDRESS:
(STREET ADDRESS / BOX NUMBER)
(CITY)
(PROVINCE)
(CODE)
(COUNTRY)
(OFFICE HOURS PHONE NUMBER)
(FAX NUMBER)
(e-mail ADDRESS)
(CELLPHONE NUMBER)
CERTIFICATE:
ENTER NAME TO APPEAR ON CERTIFICATE:
LECTURE SITE / EXAMINATION SITE:
Modules 1-3
Constantia Hotel and Conference Centre, Midrand, Johannesburg
INSUFFICIENT DELEGATE NUMBERS WILL LEAD TO THE POSTPONEMENT OR EVENTUAL CANCELLATION OF A PARTICULAR
COURSE.
AT ANY TIME DURING THE COURSE, IF YOUR E-MAIL ADDRESS CHANGES OR YOU WISH TO WITHDRAW FROM THE COURSE,
PLEASE INFORM THE GRADUATE INSTITUTE OF OPTOMETRY AS SOON AS POSSIBLE.
Refunds
Fees will be fully refundable in the case where a course is cancelled. Withdrawal from a course or module will, however, not
result in a full refund. Request will be submitted to the course directors for consideration.
Registration Number CK 98/05208/23
Members: Stef Kriel Dip.Optom .M.HPE,CAS,
The Graduate Institute of Optometry
P O Box 2409, Beacon Bay, 5205, South Africa
36 Edly Symons Avenue, Beacon Bay, 5241, South Africa
Tel/Fax: (043) 748-4901 Mobile: 082 8296084 E-mail: iod@iafrica.com Website: www.gio.co.za
Remake Examinations
There will be no remake examinations
CAS IN ADVANCED CONTACT LENSES AND INTEGRATED TREATMENT AND MANAGEMENT OF ANTERIOR SEGMENT DISEASE
AND SURGICAL MANAGEMENT
Modular
Sequence
Module 1
Module 2
Module 3
Module 4
Course Titles
Course Instructor
Advanced Contact Lens with
in-depth understanding of Rigid
Gas Permeable Lenses
Michael Wyss
( Switzerland)
Michael Bartchi
( Switzerland)
Dr Nina Mueller
(Switzerland)
Anterior Segment Disease
application of therapeutic
agents
Ocular Physiology Principles
related to Anterior Segment of
the Eye
Dr Cavallerano
( USA)
Dr Jim Mertz
(USA)
Anterior segment problems
related to dry eye and contact
lenses.
Refractive surgery and corneal
surgical techniques
Overview of relevant general &
Ocular Pharmacology and
therapeutic drugs available on
SA market
Advanced Anterior Segment
Disease with emphasis in
cornea
COST
Module 1 – R 4900.00
CPD attendance only - as
per individual modules
Dr Caroline Blackie
( USA)
Dr Janet Edeling
( SA )
Dr George Muntingh
( SA )
Dr Sleight
( USA)
Lecture Dates
Site
Cost
12 - 15 August 2010
( 5 days)
20 hours lectures and
10.5 hours workshop
Johannesburg
R 4900.00
15 – 18 October 2010
(4 days)
24 hours lectures
Johannesburg
Dates to be confirmed
4 days
24 Hours lecture
20 hours long distance
learning Dates to be
confirmed
AMOUNT DUE
CLOSING DATE
Due with
registration
by 15 June 2010
15 June 2010
Johannesburg
Web based
Select your choice
Module 1 only
Select your choice
All Modules
Confirmation of registration with confirmed course & exam dates and course year planner will be sent after the
closing date.
Direct Deposits: (Cash or cheque only)
ABSA Bank, Account Holder: Investec Private Bank- The Graduate Institute of Optometry
Account Number: 01043960306 Reference number: 10010646107 Branch Code: 632005
Electronic transfer : Investec Private Bank, Account Holder: - The Graduate Institute of Optometry .
Account number: 10010646107, Branch Code: 580105
Confirmation of payments must be faxed to 043 7484901 or E-mailed with your name clearly reflected.
No facilities are available for credit card payments.
SIGNATURE
DATE
SEE COURSE DETAILED OUTLINE AND INSTRUCTOR CV’S ON OUR WEBSITE www.gio.co.za
AND FOLLOW THE LINKS
Registration Number CK 98/05208/23
Members: Stef Kriel Dip.Optom .M.HPE,CAS,