Referral Form -Patient Self-Referral

Professional Registration Form

I am delighted to welcome you into the cohort of professionals who have become part of my learning and teaching network. Please fill out the below information to allow me to generate your access information and password.

I am looking forward to engaging with you,

Dr Naing L Tint.

Fields marked with an asterisk (*) are required.

Registered Professional Name*

GOC Registration Number*

Clinic Address

Address Line 2

City*

Post Code*

Contact Telephone Number*

Email Address*

Please write here any requests that you have for teaching materials or specific guidance:

Permission Clarification: By clicking this box I grant permission for Dr Tint and individuals working on his behalf to contact you by the means you have provided. This information will not be used for third party marketing purposes and your data will not be shared with any other companies. Please be aware that GOC numbers will be used to process CET Points where applicable.
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Following receipt of this email you will soon receive confirmation of your access within an email complete with your password and access directions. If you have any questions please feel free to get in touch using the contact tab on this website.

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Professional Registration Form

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