For Enquiries, Please Contact

SIMS-IMSE REGISTRATION FORM

Please refer to respective course brochure on the cancellation & postponement policy which varies among courses.

By providing the information set out in this form and submitting the same to us, you confirm that you have read, understood and consent to the SingHealth Data Protection Policy, a copy of which is available at http://www.singhealth.com.sg/pdpa.

COURSE DETAILS
Title :
Date & Time :
Pre-Requisite1 : / ☐ Issued by IMSE ☐ Issued by others (Please attach a copy)
PARTICIPANT DETAILS
Full Name :
NRIC / FIN / Passport No :
Institution :
Department :
Job Designation :
MCR No.
(Local doctors only) :
Tel / Mobile :
Email address :
Address
(Mailing of receipt & course manuals; if applicable) :
PAYMENT METHOD (Please check on the appropriate box)
☐ CASH
☐ CHEQUE (Payable to: Singapore Health Services Pte Ltd)
☐ TELEGRAPHIC TRANSFER (Applicable to overseas payment only)
☐ ISSUE INVOICE TO MOHH (Applicable to ACLS courses only)
☐ ISSUE INVOICE
Attention to : / All fields are mandatory for invoicing.
Email Address :
Contact number :
Institution :
Department :
Address :
ACRA No. (UEN No.) :
Purchase Order No. (if applicable):
Additional Details required for billing to SingHealth Institutions
Cost Centre No. : / Internal Order No. (if applicable) :

For enquiries, please contact:

SingHealth DukeNUS Institute of Medical Simulation (SIMS)

Institute for Medical Simulation & Education (IMSE)

Tel: (65) 6326 6885

Fax: (65) 6878 0495

Email:

Thank You for your registration.

Confirmation email will be sent once registration is confirmed.

Pre-Requisite1

– Applicable for registration of ACLS Certification course, please attach valid BCLS certificate accredited by NRC Singapore.

– Applicable for registration of ACLS Re-Certification course, please attach ACLS certificate which has not expire for more than 1 year.

– Applicable for registration of CPR+AED / BCLS / ACLS Instructor course, please attach respective valid CPR+AED / BCLS / ACLS certificate.