Registration

Family name
Middle initial
Given name
Birth date
Sex	Male     Female
Institution
Department
Address
Postal code
City
State/Province
Country
Phone
Training	NPMDPhDSocial workother
Email
Function
Lisence since
Have you had an INTERMED training?	Yes     No
Do you want to get information, such as a newsletter?	Yes   No
Do you have interest to participate in the following projects?	Self Assessment study Geriatric study Transplant study Pre operative assessment study Pediatric INTERMED (PIM) Implementatie Nederland Patient experiences Staff experiences IM-training IM-research Web-service Integrated care training
Will you use the webservice only for training?	Yes   No
Will the web service only be used by you?	Yes   No
Will the webservice be used by more persons such as a department?	Yes   No
Will the webservice be used by less than 50 persons?	Yes   No
Will the web service be used by more than 50 persons?	Yes   No