Member Application Form

Academic Title *

GenderMaleFemale

First Name(s) *

Family Name *

Date of Birth *

Date of Birth: To be published on the website? *YesNo

Nationality *

Nationality: To be published on the website? *YesNo

Medical SpecialtyPhysician / medical doctorOther (please specify):

Medical Specialty: Other

If You are physician, please specify!Orthopedic SurgeonTraumatologistOther (please specify):

If You are physician, please specify: Other

Name of Your clinic/company *

Name of Your clinic / company: To be published on the website? *YesNo

Street Address *

City *

ZIP Code *

Country *

Address: To be published on the website? *YesNo

Phone *

Phone: To be published on the website? *YesNo

Email Address *

Email: To be published on the website? *YesNo

Experience with ESWT since *

Radial ESWTFocusing ESWTRadial and focusing ESWT

What device do You use?

Do You perform ESWT on bone disorders?YesNo

Other comments (for example home address, if You prefer to be registered with the home address)

Other comments: To be published on the website? *YesNo

Please attach a photography of You, a copy of Your passport and of Your diploma *

Payment