Registration Form

Title
(eg. Dr, Prof, Ms, Mr)

First Name

Last Name

Hospital

HPCSA Registration number for Medical Practitioners (Doctors only)
(please ensure that your registration number is submitted CORRECTLY. Errors cannot be fixed)

Professional Registration number (for all specialities other than Doctors)
(please ensure that your registration number is submitted CORRECTLY. Errors cannot be fixed. Format must be eg. 'MP 1234567')

Speciality
(e.g. specialist physician, dietician, orthopaedic surgeon)

Phone Number

Email

Please let us know if you have any questions relating to withholding or withdrawing treatment and/or palliative care?

Are you and EthiQal policy holder?
NoYes

Do you agree to receive information about future webinars?
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Do you agree to receiving future correspondence from EthiQal. You can unsubscribe at any time.
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Please note that attendees must attend more than 45 minutes to be awarded 1 ethics CPD point and the full webinar to be awarded 2 ethics CPD points.
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