International CTEPH Association

Kindly complete your registration by providing the details below.

Clear name

Mandatory field Last Name*

Mandatory field First Name*

Middle Initial

Title

Mandatory field Phone*

Mandatory field Hospital / Institution / Company*

Mandatory field Classification*

Position

What is your expectation from becoming a member of the ICA?

Affiliation

Mandatory field e-Mail*

Mandatory field Street and House Number*

Mandatory field City*

Mandatory field Zip Code*

State

Mandatory field Country*

Membership benefits

Mandatory field I would like to be updated by email about ICA-related news and activities such as new projects and the triannual International CTEPH Conference (ICA will not send more than 10 messages per year):* Yes No

Mandatory field Do you agree with your name and institution to be listed under “Members” on the website of the ICA?* Yes No

Site Information

Mandatory field Does your Hospital / Institution have an ongoing program for the treatment of CTEPH patients?* Yes No

If yes, when was the program set up?

If yes, how many CTEPH patients are currently taken care of by your site?

If yes, are patients operated (undergoing PEA) at your site? Yes No

If yes, please indicate approximate number of PEAs per year

If patients are not operated at your site, where are patients normally referred to for PEA?

If yes, do patients undergo BPA at your site?

If yes, please indicate approximate number of BPA patients per year

If you have currently no program for CTEPH patients at your site, do you have plans to set up an expert center for CTEPH at your site? Please specify.

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Personal & Professional Information

Mandatory field Security question* What is the sum of 2 and 9?

Do not fill in this field