- European Society for Gynaecological Endoscopy

Last Name*

First Name*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Congress Registration Reference Number*

Please enter your Congress Registration Reference Number, which you received by e-mail after registering for the ESGE 32nd Annual Congress.

Winners ID or Academy ID*

Please enter your Winners ID or Academy ID. You can find this in your Online Scoring Platform account.

Phone*

Email*

If you have already an OSP account, please use the same e-mail.

Date of Birth*

Gender

Male
Female

Dominant hand side

Right
Left

Affiliation/Institute*

ACADEMIC INFORMATION

Current Academic Level*

Student
Resident
Specialist in Ob&Gyn
Specialist in other discipline
Other

When you chose "Specialist in other discipline/Other" please specify:

EXPOSURE TO ATYPIC PSYCHOMOTOR SKILLS

Video games

How many hours per week?*

EXPOSURE TO ATYPIC PSYCHOMOTOR SKILLS

Musical instrument

How many hours per week?*

EXPERIENCE IN HYSTEROSCOPY IN THE OR

ESGE classification is used for description of levels. Please fill in all levels.

EXPERIENCE IN LAPAROSCOPY IN THE OR

No experience in hysteroscopy

Indicate the experience in first (basic) level procedures*

These include: Diagnostic Hysteroscopy, Simple procedures (excluding the use of laser or electro-surgery), Target biopies, Removal of IUCD, Minor intrauterine adhesions

0
<30
30-50
>50

Indicate the experience in second (intermadiate) level procedures*

These include: Polyp resection, Resection of type 0 myoma, Endometrial ablation, Treatment of uterine septum, Tubal cannulation

0
<30
30-50
>50

Indicate the experience in third (advanced) level procedures*

These include: Resection of type 1 and 2 myoma, Major Asherman's syndrome

0
<30
30-50
>50

EXPOSURE WITH HYSTEROSCOPIC HANDS-ON LAB TRAINING

Animal model*

No exposure
1-2 sessions
Regular exposure (more than 2 sessions a year)

Trainer box*

No exposure
1-2 sessions
Regular exposure (more than 2 sessions a year)

Virtual reality*

No exposure
1-2 sessions
Regular exposure (more than 2 sessions a year)

EXPERIENCE IN LAPAROSCOPY IN THE OR

ESGE Classification is used for descriptions of levels. Please fill in all levels.

EXPERIENCE IN LAPAROSCOPY IN THE OR

No experience in laparoscopy

Indicate the experience in second (intermediate) level procedures*

Salpingotomy, Salpingectomy, Salpingo-oophorectomy, Cystectomy, Moderate adhesiolysis, Minimal/Mild endometriosis

0
<30
30-50
>50

Indicate the experience in first (basic) level procedures*

Diagnostic laparoscopy, Tubal sterilisation, Cyst aspiration, Biopsies

0
<30
30-50
>50

Indicate the experience in third (advanced) level procedures*

Hysterectomy, Myomectomy, Urinary incontinence, Extensive adhesiolysis, Severe endometriosis, Bowel or Bladder lesions reparation

0
<30
30-50
>50

Indicate the experience in fourth level procedures*

Pelvic floor disorders, Oncology (Lymphadenectomy, Radical hysterectomy, Axiloscopy), Recto-vaginal endometriosis

0
<30
30-50
>50

EXPOSURE WITH LAPAROSCOPIC HANDS-ON LAB TRAINING

Animal model*

No exposure
1-2 sessions
Regular exposure (more than 2 sessions a year)

Trainer box*

No exposure
1-2 sessions
Regular exposure (more than 2 sessions a year)

Virtual reality*

No exposure
1-2 sessions
Regular exposure (more than 2 sessions a year)

GESEA Robotics Practical Training

Specify for which session you wish to enroll during the ESGE 32nd Annual Congress in Brussels, Belgium.

Training*

Preferred Date*

Please indicate your preferred date for your session (Oct 2nd or Oct 3rd). Please note that as places are limited, your preferred date may not be available and you will be allocated a place in the next available session.

Total

0,00 €

Payment type*

Credit Card
Bank Transfer

Credit Card

Please check if you have activated a Stripe feed for your form.

ESGE account information
IBAN: BE63 3630 8342 6508
BIC: BBRUBEBB
Bank address: ING Leuvensesteenweg 203, 3390 Sint-Joris-Winge, Belgium
Reference: Your name and session title

Consent*

I have read and agree with the terms of use and the privacy policy of the European Society for Gynaecological Endoscopy

ESGE 32nd Annual Congress: Registration GESEA Robotics Practical Training Session

ACADEMIC INFORMATION

EXPOSURE TO ATYPIC PSYCHOMOTOR SKILLS

EXPERIENCE IN HYSTEROSCOPY IN THE OR

EXPOSURE WITH HYSTEROSCOPIC HANDS-ON LAB TRAINING

EXPERIENCE IN LAPAROSCOPY IN THE OR

EXPOSURE WITH LAPAROSCOPIC HANDS-ON LAB TRAINING

GESEA Robotics Practical Training

Principal Sponsors of the ESGE