* - required

*Title:

Or:

*Name:

*Surname:

*Position:

*Hospital:

*Correspondence
address:

Address line 2:

Address line 3:

*Post Code:

*Email Address:

*Re-type Email:

*Tel (work):

Tel (home):

Mobile:

*I am happy for this email address to be used to invite me to future meetings

Yes

*I am a healthcare professional working in the UK:

Yes

Please tick if you have any special dietary requirements:

Vegetarian

Vegan

Other:

This meeting has a limited number of places available and will be offered to delegates on a first come, first served basis. Your place cannot be guaranteed until you receive confirmation from us

west midlands

13th October 2009

Maple House Birmingham