Intra Uterine Device Insertion Form

STANDARD REGISTRATION $1000 GST INCLUSIVE

Please complete the following form to register for the 2024 IUD insertion course for General Practitioners. You will receive an email confirming your enrolment, including practical component allocation and instructions for payment.

Please contact Agora Medical Education if you have any question or queries regarding the course: education@agoracentre.com.au

Name

First Name

Last Name

RACGP QI & CPD Number

Mobile Phone

Email Address

Practice Name

Practice Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Dietary Requirements

Theory Component and Practical Simulation Based Station

Date TBC This component is a prerequisite for the practical component. Failure to attend this session will prevent you from participating in the practical session.

TBC

Practical Component

AM session 8.00AM to 11.30AM | PM session 1.00PM to 4.30PM Please list three options in order of preference from the following dates (we will endeavor to accommodate your first preference if possible): Date TBC

Please Answer The Following

How Many Doctors Are In Your Practice

What Percentage Of Your Practice Is Women's Health

Are You Currently Inserting IUDs

How Many IUDs Do You Think You Would Be Inserting A Month Post Course

Can You Bring Two Of Your Patients For IUD Insertion For The Practical Component?

We encourage GPs to recruit patients for the practical component of the course. If not possible we will assist in the recruitment process

Currently Where Do You Refer Your Patients Who Need IUDs

How Did You Hear About The Course?

Cancellation Policy

All cancellations must be made in writing. Cancellations received more than 30 days prior to the practical course date will receive full refund minus $80.00 administration fees. A refund of 50% of the registration fee will be made on cancellations received less than 30 days prior to the practical course date.

In the event of the course being cancelled for any unforeseen reason, registrants will be notified no later than 2 weeks prior to course commencement date and a full refund will be issued.