Training Registration Form

Nexon Endoscopic Spine Mastery Pathways

CAPTCHA

Select training(Required)

Select training date(Required)

Distributor Contact Information

Are you a distribution partner?(Required)

Yes

Name Distribution Partner(Required)

First Name Last Name

Company and Country(Required)

Email Distributor(Required)

Email Address Confirm Email Address

Are you interested in Sales training?(Required)

Yes

(Expected to run from 13:00 - 17:00 on the first day of the Module 1 training.)

Who from your team will accompany the surgeons on the learning platform?(Required)

First Name Last Name

Email(Required)

Surgeon Contact Information

Title

Name Surgeon(Required)

First Name Last Name

Email Surgeon(Required)

Email Address Confirm Email Address

Mobile Phone Surgeon(Required)

Hospital(s)(Required)

Address

Street Address City ZIP / Postal Code

Country(Required)

Ortho / Neuro(Required)

Ortho

Neuro

In which year did you start your Spine experience (after Residency)?

Fellowship Location / Year

Pre-Training Preparation Checklist

First surgery planned?(Required)

Yes

Planned surgery date

Proctor wished for first surgery?(Required)

Yes

Instrument set available?(Required)

Yes

Expected availability date

Is an expected budget approval date available for system evaluation or purchase?(Required)

Yes

Expected approval date

Your training objectives

in order of importance

Training objectives

Interest in Product Demonstrations

MIS Pedicle Screw

Open Pedicle Screw

TLIF

ACDF

LLIF

Dietary Restriction

Vegetarian

Vegan

Gluten-free

Others:

2nd Surgeon

Do you want to register additional surgeons?(Required)

Yes

Title

Name Surgeon(Required)

First Name Last Name

Email Surgeon(Required)

Email Address Confirm Email Address

Mobile Phone Surgeon(Required)

Hospital(s)(Required)

Address

Street Address City ZIP / Postal Code

Country(Required)

Ortho / Neuro(Required)

Ortho

Neuro

In which year did you start your Spine experience (after Residency)?

Fellowship Location / Year

Pre-Training Preparation Checklist

First surgery planned?(Required)

Yes

Planned surgery date

Proctor wished for first surgery?(Required)

Yes

Instrument set available?(Required)

Yes

Expected availability date

Is an expected budget approval date available for system evaluation or purchase?(Required)

Yes

Expected approval date

Your training objectives

in order of importance

Training Objectives

Interest in Product Demonstrations

MIS Pedicle Screw

Open Pedicle Screw

TLIF

ACDF

LLIF

Dietary Restriction

Vegetarian

Vegan

Gluten-free

Others:

Others

3rd Surgeon

Do you want to register another surgeon?(Required)

Yes

Title

Name Surgeon(Required)

First Name Last Name

Email Surgeon(Required)

Email Address Confirm Email Address

Mobile Phone Surgeon(Required)

Hospital(s)(Required)

Address

Street Address City ZIP / Postal Code

Country(Required)

Ortho / Neuro(Required)

Ortho

Neuro

In which year did you start your Spine experience (after Residency)?

Please enter a number from 1980 to 2030.

Fellowship Location / Year

Pre-Training Preparation Checklist

First surgery planned?(Required)

Yes

Planned surgery date

Proctor wished for first surgery?(Required)

Yes

Instrument set available?(Required)

Yes

Expected availability date

Is an expected budget approval date available for system evaluation or purchase?(Required)

Yes

Expected approval date

Your training objectives

in order of importance

Training objectives

Interest in Product Demonstrations

MIS Pedicle Screw

Open Pedicle Screw

TLIF

ACDF

LLIF

Dietary Restriction

Vegetarian

Vegan

Gluten-free

Others:

Others

4th Surgeon

Do you want to register another surgeon?(Required)

Yes

Title

Name Surgeon(Required)

First Name Last Name

Email Surgeon(Required)

Email Address Confirm Email Address

Mobile Phone Surgeon(Required)

Hospital(s)(Required)

Address

Street Address City ZIP / Postal Code

Country(Required)

Ortho / Neuro(Required)

Ortho

Neuro

In which year did you start your Spine experience (after Residency)?

Fellowship Location / Year

Pre-Training Preparation Checklist

First surgery planned?(Required)

Yes

Planned surgery date

Proctor wished for first surgery?(Required)

Yes

Instrument set available?(Required)

Yes

Expected availability date

Is an expected budget approval date available for system evaluation or purchase?(Required)

Yes

Expected approval date

Your training objectives

in order of importance

Training objectives

Interest in Product Demonstrations

MIS Pedicle Screw

Open Pedicle Screw

TLIF

ACDF

LLIF

Dietary Restriction

Vegetarian

Vegan

Gluten-free

Others:

Others

5th Surgeon

Do you want to register another surgeon?(Required)

Yes

Title

Name Surgeon(Required)

First Name Last Name

Email Surgeon(Required)

Email Address Confirm Email Address

Mobile Phone Surgeon(Required)

Hospital(s)(Required)

Address

Street Address City ZIP / Postal Code

Country(Required)

Ortho / Neuro(Required)

Ortho

Neuro

In which year did you start your Spine experience (after Residency)?

Fellowship Location / Year

Pre-Training Preparation Checklist

First surgery planned?(Required)

Yes

Planned surgery date

Proctor wished for first surgery?(Required)

Yes

Instrument set available?(Required)

Yes

Expected availability date

Is an expected budget approval date available for system evaluation or purchase?(Required)

Yes

Expected approval date

Your training objectives

in order of importance

Training objectives

Interest in Product Demonstrations

MIS Pedicle Screw

Open Pedicle Screw

TLIF

ACDF

LLIF

Dietary Restriction

Vegetarian

Vegan

Gluten-free

Others:

Others

Practical information

Shall we reserve a hotel room?

Yes, for the registred surgeon(s)

additionally for other participants (Sales, Distributor, Nurses...)

Costs ca. CHF 155 per person, is not included in the course fee

Total number of persons (including surgeon(s))

Travel Plans

Plane

Train (from airport to training location, recommended)

Car

Arrival Time

if already known

Departure time

if already known

Your Comments/Questions

Data Agreement(Required)

I agree that the personal data provided in this form may be stored in the company’s CRM for communication regarding future trainings and updates. I understand that I can withdraw my consent at any time.

Cancellation Terms(Required)

I confirm that I am booking this training with payment obligation and accept the cancellation terms (full refund up to 30 days before the training; 75% voucher up to 15 days before; 30% voucher thereafter, redeemable for future trainings).

Overbooking Clause(Required)

I acknowledge that in the rare case of overbooking, Nexon Medical AG reserves the right to offer an alternative training date.

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EnSight™ UBE Module 1 Interlaminar Approach for Unilateral Spinal Decompression - 3 surgeons

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EnSight™ UBE Module 1 Interlaminar Approach for Unilateral Spinal Decompression - 4 surgeons

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EnSight™ UBE Module 1 Interlaminar Approach for Unilateral Spinal Decompression - 5 surgeons

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EnSight™ UBE Module 3 Foraminal Approach for Decompression / Module 4 Transforaminal Approach for Fusion - 3 surgeons

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EnSight™ UBE Module 3 Foraminal Approach for Decompression / Module 4 Transforaminal Approach for Fusion - 4 surgeons

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EnSight™ UBE Module 3 Foraminal Approach for Decompression / Module 4 Transforaminal Approach for Fusion - 5 surgeons

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EnSight™ UBE Module 5 Posterior Cervical Foraminotomy and Decompression - 4 surgeons

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EnSight™ UBE Module 5 Posterior Cervical Foraminotomy and Decompression - 5 surgeons

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Total

Please select your payment method(Required)

Credit card

Invoice

Credit Card

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Nexon Endoscopic Spine Mastery Pathways

Distributor Contact Information

Surgeon Contact Information

Pre-Training Preparation Checklist

Your training objectives

2nd Surgeon

Pre-Training Preparation Checklist

Your training objectives

3rd Surgeon

Pre-Training Preparation Checklist

Your training objectives

4th Surgeon

Pre-Training Preparation Checklist

Your training objectives

5th Surgeon

Pre-Training Preparation Checklist

Your training objectives

Practical information

Mission Statement:

Contact:

Adress:

FOLLOW US:

More Information: