EAGLE - LASER - European Associated Group of Endovenous Laser Evaluation

Cl. Histories:	141
Doctors:	42

Only Authorized

DOCTOR / USER INFORMATION

Note: The fields with * are obligatory.
Collaborator Dr.: If you want to be a collaborator doctor, please send us your curriculum and if it is posible your personal photo.

PERSONAL DATA

To enclose photo: (Note: Only "jpg" or "gif" image file)

First Name * :

Family Name * :

Address * :

Region / District * :

If you do not find your Region / District in the dialogue box , please, fill the next 3 fields ( country, city, and Region / District ). If your country is not in the list, that is because nobody in your country works with us. Althought, if you should be interested in our team, do not hesitate in contact us via e-mail.
Country:
City:
Region / District:

Postal Code * :

Telephone * :

Cell / Mobile:

E-Mail * :

PROFESIONAL DATA

Hospital * :

If you do not find your hospital in the dialogue box, please, fill the next fields ( name, direction, telephone, country, city, and Region / District ) of your work hospital.
Name:
Direction:
Telephone:
Country:
City:
Region / District:

Speciality * :

DATA TO ACCESS THIS WEB

User Name * : ( max. 10 chars )

Password * : ( max. 10 chars )

Confirm Password * :

DO YOU WANT TO BE EAGLE-LASER COLLABORATING DOCTOR ?

Colaborator: In this web you can manage your histories for 50.00 €/year, and get your own statistics and national statistics.
Yes, i want to be a colaborator and pay.

We have the 3D-Secure Code System to pay via internet. It is a code that only you known. This system is more secure for you, because if you lose your card, nobody can pay here with it. The system is similar to a "automatic cash bank", where you must enter a personal code. You can get this 3D-Secure code in your bank. This code is not the 3 digits that follows the other 16 digits.

Do you use endovenous laser? Yes No

To enclose curriculum:
(Note: Only "doc" or "txt" document file are accepted)

Observations:

I authorize to Eagle-Laser to publish in this Web the data provided in this form

I have read and accepted the legal conditions

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