Please enable JavaScript in your browser to complete this form.
Seminar Application Form
Application for
Hybrid Coagulation Empowerment Network:
Patient centric interdisciplinary team approach concepts (PCITAC) - (Cardiac) Surgery and OB/GYN
Zurich, February 25 – February 28, 2025
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Email
*
Personal Information
Applicant
*
First
Last
Date of Birth
Phone
*
Professional Position
Affiliation or Institution
*
Department
*
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Please upload your CV
*
Drag & Drop Files,
Choose Files to Upload
Next
Professional Experience
Publication History
Please cite your most relevant professional publications here (maximum 5)
Please list 5 fields of special scientific or clinical interest from the list below. you may add your own
*
Hematology
Obstetrics and gynaecology
General Anaesthesiology
Pediatric Anaesthesiology
Anemia
Cardiac Surgery
Hospital organisation and Workflow
Other…
other fields:
list your other fields here (one per line please)
Next
Case Presentation
Would you be willing to prepare, submit and Present a case Presentation (5 - 7 minutes) related the subject of the course medical field?
yes
no
Please select the medical field(s) to which your case presentation corresponds:
*
Hematology
Obstetrics and gynaecology
General Anaesthesiology
Pediatric Anaesthesiology
Anemia
Cardiac Surgery
Hospital organisation and Workflow
Other…
field for case presentation
enter the subject here
Case Description
Please describe your clinical case study here. If you prefer to provide a file, please either upload it below send it to us by email at mailto:jgassner@gigajo.at
File Upload
Drag & Drop Files,
Choose Files to Upload
upload here (optional)
Next
Your Interest and Motivation
What motivates you to apply for this course?
*
What do you expect to gain from participating in this course?
*
How might you be able to contribute with your own background, skills and experience?
*
Agree to have my info retained in order to be informed of future events.
Please retain my info to keep me notified of future events.
Should you not be successful in your application this time, we can retain your details and inform you of future events.
GDPR Agreement
*
I consent to having this website store my submitted information so they can respond to my inquiry.
Apply
