Registration Forms - Laser Therapy Pavia

Filling Instructions

Filling in all fields is mandatory to enable the print button.

Once printed and signed with a pen, the forms must be scanned and sent by email to: corsi@laserdermo.com.

The registration application will be considered valid and accepted exclusively following payment of the required fee.

Registration Form

Basic Course of Laser Therapy in Dermatology

April 11 and 12, 2026 - Multispecialty Medical Center, Via Mario Ponzio 15, Pavia

Participant Details

First Name:

Last Name:

Home Address:

City:

Mobile Phone:

Medical Board No.:

Email:

Billing Details

Company Name (or First/Last Name):

Billing Address:

City:

ZIP Code:

Tax Code / VAT Number:

SDI Code (if applicable):

Certified Email (PEC):

Module Cost

€ 1.800 + VAT (Registration by 02/28/2026) € 2.000 + VAT (Registration after 02/28/2026)

Registration is strictly reserved for graduates in Medicine and Surgery. Courses have limited spots (maximum 7 participants); applications will be accepted based on the chronological order of receipt.

The course organizers reserve the right to make changes to the programs and dates, up to the possible cancellation of the course, no later than 10 days from the start date. In case of cancellation, the learner will be fully refunded the fee paid. Substitution of the participant's name with another subject is permitted, subject to written communication, to be carried out no later than 15 days before the start of the course. In case of withdrawal by the learner, no refund of the fees paid is provided, including any amounts paid as pre-registration.

The possibility of video recording and/or photographing during the course is established, from time to time, at the unquestionable judgment of the event organizers.

This registration form must be fully completed and sent to the email address: corsi@laserdermo.com. The registration application will be considered valid and accepted exclusively following payment of the required fee.

Payment method: Bank Transfer - UniCredit
Account holder: M2M Group srl
IBAN: IT21C0200811304000041201967 - BIC: UNCRITMID14
Reason: Laser Course Registration APR26

Date of filling:

Signature:

Sign with pen after printing

Consent to the processing of personal data (mandatory)

By signing this document, I declare that I have carefully read the contents of the privacy policy provided by you pursuant to EU Regulation No. 679/2016.

Date of filling:

Signature:

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Declaration Form

Basic Course of Laser Therapy in Dermatology

Participant Details

First Name:

Last Name:

Place of birth:

Date of birth:

Degree in:

Medical Board No.:

Profession:

City:

Address:

ZIP Code:

Declares:

To possess professional liability insurance with the Company:

Therefore, the same insurance company will be called into question in the event of complications complained of by patients after their work.

To NOT possess professional liability insurance and to respond personally in the event of patient complaints after their work.

Immediately exonerates the medical facility located in Pavia in Via Mario Ponzio 15, where the treatments will be carried out, from any request for compensation that may arise for damage that may result to patients treated with their professional work.

Date of filling:

Signature:

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Furthermore Declares:

To have received the information referred to in Article 13 of the GDPR. I express my consent to receive informational material relating to upcoming events/courses scheduled.

I AGREE I DO NOT AGREE

Aware that false declarations, falsehood in documents and the exhibition of a false document or one containing data no longer corresponding to the truth are punished by the Penal Code, I declare the truthfulness of the info contained in the CV pursuant to D.P.R. 445/2000.

Date of filling:

Signature:

Sign with pen after printing

Remember to attach to the email: Valid ID document and Curriculum Vitae

INFORMATION RELATING TO THE PRIVACY LAW
Pursuant to the European Data Protection Regulation no. 2016/679 (GDPR), the personal data provided above will be processed in compliance with the aforementioned legislation with the support of paper and/or computer means, or in any case using tools suitable to guarantee security and confidentiality. The scope of processing will be reserved for the Italian territory and the data may be communicated for promotional and/or scientific purposes as well as for sending informational material of an exclusively scientific nature to subjects who, in collaboration with the data controller, have participated in the organization of this initiative or other future projects. The data will be kept for the time strictly necessary for the pursuit of the stated purposes. M2M Group srl guarantees the possibility to exercise the rights referred to in Articles 15 to 22 of the GDPR and therefore to know, obtain the cancellation, rectification, updating and integration of data as well as to oppose their use for the stated purposes. The Data Controller is M2M Group srl based in Via Mario Ponzio 15, Pavia, email address: corsi@laserdermo.com

Laser Therapy in Dermatology - Forms

Registration Form

Basic Course of Laser Therapy in Dermatology

Participant Details

Billing Details

Module Cost

Declaration Form

Basic Course of Laser Therapy in Dermatology

Participant Details

Declares:

Furthermore Declares: