Saudi National Bariatric Registry [SNBR] - LIVE Registration Request Form

SNBR LIVE Registration Request Form

Name

Job Title / Role

Organization

E-Mail

P.O. Box

Telephone No.

Fax No.

Mobile No.

Direct Supervisor

Direct Supervisor Job Title

I confirm that my contact details can appear in a members’ interest booklet:

Yes No

I confirm that my contact details can appear in the Saudi National Bariatric Registry website:

Yes No

(All amendment will be confirmed with you and you can change your information at any stage)