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Registration to the conference

Nationality
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Name
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Surname
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Place of residence
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Email
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Birth
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Tel. Home
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Tel. Office
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Tel. Mobile
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Male / Female
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Speciality
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Hospital / Office
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Hospital / Office address
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Have you ever experienced any healing cases by prayer ?
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Do you have some divine healing cases that you want to present at the international Christian medical conference ?
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I'll arrive to Rome the:
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At:
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Place of arrival:
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I'll arrive:
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I will stay for one night in the hotel:
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I'll leave Rome the:
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At:
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Place of departure:
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Particular recommendations:
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