Application to Join the Independent Worldwide Endobarrier Registry and Gain Access to the On-line Registry Tool

In order to join the registry, you need to agree that the registry organisers are allowed to see all the details above about you and your site/centre. The registry organisers will be analysing only anonymised patient data, but they are not prepared to receive data from anonymised contributors. Please tick the boxes to agree to this and that we may contact you at any time about anything to do with this registry and to invite you to join future audits that might be applicable to you.

Your Details

Title ^*

First Name ^*

Last Name ^*

Designation ^*

Other Designation

Specialty ^*

Other Speciality

City/Town ^*

The city or town in which the hospital is based

Postcode ^*

Country ^*

County ^*

Hospital / Institution

Please provide the full name of your Hospital, University, General Practise surgery etc. Please do not abbreviate.

Phone Number ^*

Email ^*

How we will use your data

I agree that ABCD may contact me at any time about this registry

I would like to be invited to join future audits that might be applicable to me

Further Information

(including your Centres experience with EndoBarrier, approximate number of patients etc)

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Gold

Silver

Bronze

Gold

Silver

Bronze

Application to Join the Independent Worldwide Endobarrier Registry and Gain Access to the On-line Registry Tool

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