LASIK at New Vision Laser Centers – Registration form for Lasik Course - LASIK India

Registration For Lasik Course

Posted on August 30, 2010

Dr. ( Mr. / Mrs. / Ms.): *

Surname

First name *

Sex

Male

Female

Date of birth: Day *

Date of birth: Month *

Date of Birth: Year *

Age *

Qualifications *

Institution *

Mailing Address *

City *

State *

Postal Code

Telephone *

Fax

Email *

COURSE FEE :

Hotel booking required ?

Yes

PAYMENT: I enclose a Cheque / Bank Draft No *

Dated *

for Rs.22060.00, drawn on Bank *

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

Date *

2010