GENIUS IUS workshop Expression of Interest

First Name *

Last Name

Preferred NameIf different to name above

Email Address *

Secondary Email AddressIf your primary email may change due to changing workplace please provide a secondary email you can be contacted on.

Where is your primary place of practice? *

What is your current role? *

Have you completed GENIUS online theory module (Part 1)? *YesNo

Have you commenced practical placement? *YesNo

If yes how many scans have you currently completed?

If you have a start date for your IUS practical placement please confirm

Day

Month

Year

Please confirm who your supervisor will be for practical placement if known

Please confirm your primary location for practical training if known