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Doctors – SHS Members
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Membership No. *
Membership Certificate Upload
Please upload the Membership Certificate
Title *
Prof.
Dr.
Mr.
Ms.
First Name *
Last Name *
Date Of Birth *
Mobile *
Email *
Affiliation/Institute *
Designation
Professional Qualification and Year(Optional)
Address *
City*
State *
Country *
PIN Code *
No. Of Accompanying Person
None
1
2
3
Virtual Simulation workshops 9th December (optional)
None
Human factors in Simulation
Advanced Debriefing workshop
Select Workshops
(optional)
Pre-Conference Workshops
Post-Conference Workshops
Workshop Rajahmdundry
(optional)
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Simulation in Dentistry (7th Dec)
Cadaveric Simulation (8th Dec)
Accompany Person 1 Name *
Age *
Gender *
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Male
Female
Accompany Person 2 Name *
Age *
Gender *
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Male
Female
Accompany Person 3 Name *
Age *
Gender *
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Male
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Accompany Person 4 Name
Age
Gender
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Life Time Membership
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