Application Form - Becoming part of the European group on Graves Orbitopathy

Application form for GROUPS aiming at becoming part of the EUROPEAN GROUP ON GRAVES ORBITOPATHY

IMPORTANT: NO PROFORMAS
Please be advised that the use of clinical proformas for membership applications has been discontinued.

Meeting Fees
Please be advised that upon the successful acceptance of a centre, each individual member is required to pay their respective membership fees. These fees are mandatory to activate and maintain professional status once the centre’s application has been approved.
Annual membership fee: 60 Euros

Please ensure you list all team members email addresses in the below fields.

Applicants need to submit any outstanding paperwork within 3 months of application, otherwise application will be deleted.

Application Form – Becoming part of the European group on Graves Orbitopathy

Principal Endocrinologist

Name of Principal Endocrinologist

Job Title

Name of Institution

Address

EUGOGO Teaching Course Attended?

Yes

If yes specify which course

If yes upload certificate of attendance

Maximum file size: 10MB

Principal Ophthamologist

Name of Principal Ophthalmologist

Job Title

Name of Institution

Address

EUGOGO Teaching Course Attended?

Yes

If yes specify which course

If yes upload certificate of attendance

Maximum file size: 10MB

Joint GO clinic

We confirm that we have a Joint GO clinic

Where the patient, endocrinologist and ophthalmologist have a joint discussion about GO management in in the same clinic

Specify Frequency and Format of Joint Clinics

Weekly

Monthly

OtherOther

Please list names and roles of other members of your team involved in the care of patients with Graves’ Ophthalmopathy

Name

Role

Job Title

EUGOGO Teaching Course Attended?

Yes

If yes upload certificate of attendance

Maximum file size: 10MB

Add Remove

Please describe the clinical service that you provide for patients with Graves’ ophthalmopathy and how it is delivered. Please describe in detail the multidisciplinary nature of your service

Please describe the sources of referral to your centre, including the approximate numbers of new cases that are seen annually

If there is a standard operating protocol for your GO care please upload this here

Maximum file size: 10MB

Please provide approximate numbers of patients who receive various treatments the name of the physician / surgeon responsible and the name and place of the hospital where these treatments are administered

Steroids

Number of patients receiving high dose steroids per annum

Name of responsible clinician supervising treatment

Name of Hospital

City of Hospital

Orbital irradiation

Number of patients receiving orbital irradiation per annum

Name of responsible clinician supervising treatment

Name of Hospital

City of Hospital

Second Line Biologic/ Immunosuppression

(describe your protocol here and the protocol you use)

Orbital Decompression

Number of patients receiving orbital decompression per annum

Name of responsible clinician supervising treatment

Name of Hospital

City of Hospital

Strabismus surgery (for GO patients only)

Number of patients receiving strabismus surgery per annum

Name of responsible clinician supervising treatment

Name of Hospital

City of Hospital

Lid surgery (for GO patients only)

Number of patients receiving Lid surgery per annum

Name of responsible clinician supervising treatment

Name of Hospital

City of Hospital

Scientific Output

Peer Reviewed publications in the field of Graves’ orbitopathy

Involvement in Clinical Trials Y/N

Yes

If YES please list

Involvement in EUGOGO Projects Y/N

Yes

If YES please list

Recommendation by another EUGOGO Centre Y/N

Yes

If yes please upload letter of recommendation

Maximum file size: 10MB

Case Studies

Please upload 3 cases of complex GO patients managed at your centre from presentation to outcome (entire patient care journey) that are representative of the case mix seen at your centre. Please be advised that the use of clinical proformas for membership applications has been discontinued.

Please include as much details of the Ophthalmic & Endocrine clinical presentation as possible but please ensure full anonymisation.

Case study 1

Maximum file size: 10MB

Case study 2

Maximum file size: 10MB

Case study 3

Maximum file size: 10MB

Declaration

I confirm that all the information provided in this application is accurate and truthful to the best of my knowledge. I understand that eligibility for membership is determined in accordance with the criteria set out in the Society’s constitution, and I acknowledge that the information I have submitted will be assessed against those standards.

Signed

Clear

Name

Position

Institution

Date

If you are human, leave this field blank.