Hearing Implant Information Day - BIRMINGHAM

Saturday 3rd December - Registration Form

Please complete all fields below as this will enable us to plan the day accordingly and cater for any additional needs or dietary requirements.

We look forward to meeting you on the day and should you require any further information in advance please do not hesitate to get in touch with us by using the contact details below -

Freephone - 0330 123 5601*

Email - conferences@medel.co.uk

*please check with your network operator as fees may apply

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* 1. First Name

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* 2. Surname

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* 3. Email address

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* 4. How did you hear about this event?

Through my clinic

Eventbrite

Facebook

MED-EL website

Other

Other (please specify)

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* 5. Have you previously attended one of our Information days or webinars?

Yes

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* 6. Are you a candidate, existing user or care provider? (Please select)

Candidate

User

Care Provider (Adults)

Care Provider (Child)

Professional (Teacher/Clinician)

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* 7. Which implant are you currently using or considering?

Cochlear Implant

Middle Ear Implant (VIBRANT SOUNDBRIDGE)

Bone Conduction (BONEBRIDGE)

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* 8. Please list any dietary requirements

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* 9. If you are being accompanied, please provide their details below, ie: Name and relationship to you?

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* 10. *Privacy Notice

The information we capture in this form will only be used in conjunction with the event or open day that you are signing up for. Once that purpose is complete, we will delete your data within 6 months.
You can view our full privacy policy here: https://www.medel.com/en-gb/privacy-policy

If you have any questions or would like your data deleted, please contact:
conferences@medel.co.uk

I understand the Privacy Policy

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* 1. First Name

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* 2. Surname

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* 3. Email address

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* 4. How did you hear about this event?

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* 5. Have you previously attended one of our Information days or webinars?

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* 6. Are you a candidate, existing user or care provider? (Please select)

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* 7. Which implant are you currently using or considering?

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* 8. Please list any dietary requirements

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* 9. If you are being accompanied, please provide their details below, ie: Name and relationship to you?

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* 11. If you have a hearing loss, do you require any assistive equipment?