ICON :: Oncology India

* Title :
* First Name :
Middle Name :
* Last Name :
* User Name :
* Address :
* City :
* State :
* Country :
* Pin Code :
* Telephone :
Fax :
* Mobile :
* Email :
Alternate Email :
I prefer all correspondence to be be at : Clinic / Hospital address Residence Address
* I will devote approximately percentage of my professional hours a week to Oncology.

Hospital & Clinic Details

Hospital / Clinic Name :
Department :
Address :
City :
State :
Country :
Pin Code :
Telephone :
Fax :

Compliance

Before submitting this form please read the conditions you are required to abide by.

Affirmation of Integrity | Conflict of Interest | Constitution

You must agree with all three conditions below to become a member. By submitting this form you are affirming that you have understood, agree and will comply ICON's terms and conditions to become a member.

I agree with the Constitution and Bye Laws of ICON

I agree that all activities will be conducted with the patient's interest being of primary importance.

I agree that membership will require my ongoing commitment and active contribution to the activities of ICON.

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