Laser Eye Surgery
Lasik Eye Surgery Center
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Doctor's Corner

Registration Form for Lasik Course

                           Surname                                                            First name
  1.
Dr. ( Mr. / Mrs. / Ms.): Male Female
 
       
       
  2.

Date of birth
Day:
Month:
Year:
Age
 
       
       
  3.
Qualifications  Institution
 
 
         
  4 Mailing Address City         
    State        
Postal Code      
       
  5 Telephone

Fax    

Email    

 
 
       
    COURSE FEE       : Rs.16,530.00 ( Rs.15, 000.00 + 10.2% Service Tax )
                              ( Non - refundable / Inclusive of 4 Lunches, 1 Dinner, Tea & Coffee etc.) 		 
       
  6. Hotel booking required ? Yes No    
 
 
PAYMENT
I enclose a Cheque / Bank Draft No     Dated for  Rs.16,530.00 , drawn on

Bank ,  payable to New Vision Laser Centers ( Rajkot ) Pvt. Ltd.,  Vadodara. ( All outstation payments by D.D. Only )

Date   2004
 
       
 
 

 


 
  22nd Intensive LASIK Course