Course Registration Form
Pre-requisite for all Physiohealth & NOI India Courses
* Required
Name
*
(will appear on the Certificate)
Your answer
Gender
*
Male
Female
Required
Email
*
Your answer
Mobile Number
*
Your answer
Alternate Contact Number
Your answer
Current Address
*
Your answer
PIN Code
*
Your answer
City
*
Choose
Agra
Ahmedabad
Alappuzha
Alwar
Amritsar
Aurangabad
Bangalore
Bharatpur
Bhavnagar
Bhikaner
Bhopal
Bhubaneshwar
Bodh Gaya
Calangute
Chandigarh
Chennai
Chittaurgarh
Coimbatore
Cuttack
Dalhousie
Dehradun
Delhi
Diu-Island
Ernakulam
Faridabad
Gangtok
Gaya
Ghaziabad
Gurgaon
Guwahati
Gwalior
Haridwar
Hyderabad
Imphal
Indore
Jabalpur
Jaipur
Jaisalmer
Jalandhar
Jamshedpur
Jodhpur
Junagadh
Kanpur
Kanyakumari
Khajuraho
Khandala
Kochi
Kodaikanal
Kolkata
Kota
Kottayam
Kovalam
Lucknow
Ludhiana
Madurai
Manali
Manali
Mangalore
Margao
Mathura
Mountabu
Mumbai
Mussoorie
Mysore
Nagpur
Nainital
Noida
Ooty
Orchha
Panaji
Patna
Pondicherry
Porbandar
Portblair
Pune
Puri
Pushkar
Rajkot
Rameswaram
Ranchi
Sanchi
Secunderabad
Shimla
Surat
Thanjavur
Thiruchchirapalli
Thrissur
Tirumala
Udaipur
Vadodra
Varanasi
Vasco-Da-Gama
Vijayawada
Visakhapatnam
International Participant
Other
State/Union territory
*
Choose
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadar and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry (Pondicherry)
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
International Participant
Qualification
*
Bachelor of Physiotherapy (BPT)
Bachelor of Science in Physiotherapy (BSc PT)
Master in Physiotherapy (MPT)
Master of Science in Physiotherapy (MSc PT)
Physiotherapist Intern (Not eligible for the Neuromuscular Dry Needling - Basic & Advanced courses)
Other:
Required
Academic Institute
*
(graduated from/currently studying in)
Your answer
Food
Jain
Non-Jain
Not Applicable for Online Course
Beverage
Tea
Coffee
Neither
Not Applicable for Online Course
Food Allergies (if any)
Your answer
Course Options
*
Explain Pain Online 16/17/23/24 January 2021
Terms
1. Video recording is not allowed.
2. Course fee is non‐refundable unless the event is cancelled.
3. Swapping courses is not allowed. A replacement is allowed.
4. Event organisers reserve the right to reschedule the course if required with prior notice.
Contact us (in case of queries/concerns)
Address: Physiohealth, East View C H S Ltd., Ground Floor,
Corner of 4th Road & Khar Pali Road, Khar West, Mumbai - 400052
Phone: +91-7738 200600 | +91-22-2604 3336
Email:
info@physiohealth.in
Website:
physiohealth.in
Next
Never submit passwords through Google Forms.
Forms
This content is neither created nor endorsed by Google.
Report Abuse
Terms of Service
Privacy Policy