ICHOM Connect Registration Form

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Salutation:* Salutation is Required

Organization:* Organization is Required

Organization type:* Organization type is Required

What type of provider?: What type of provider? is not valid

What is the size of your organization?: What is the size of your organization? is not valid

If you are part of a Hospital, how many beds do you have?: If you are part of a Hospital, how many beds do you have? is not valid

What is the main/leading reason you are joining ICHOM Connect today?:* What is the main/leading reason you are joining ICHOM Connect today? is Required

Are you or have you been part of one of our Working Groups? :* Are you or have you been part of one of our Working Groups? is Required

Has your organisation sponsored a Set of Patient-Centered Outcome Measures?:* Has your organisation sponsored a Set of Patient-Centered Outcome Measures? is Required

Username:* Invalid Username

Email:* Invalid Email

I have read and agree to the Terms of Service & Terms and Conditions*

This site collects names, emails and other user information. I consent to the terms set forth in the Privacy Policy.

You are responsible for protecting your Login Credentials from unauthorized use, and you are responsible for all activity that occurs on your Account (including, without limitation, financial obligations). You agree to notify us immediately if you believe that your Login Credentials have been or may be used without your permission so that appropriate action can be taken.

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Membership

ICHOM Connect Registration Form

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Membership

ICHOM Connect Registration Form

CONTACT US

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