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 Principal Endocrinologist Name of Principal Endocrinologist * Job Title * Email * Name of Institution * Address * EUGOGO Teaching Course Attended? * Yes No If yes specify which course * If yes upload certificate of attendance * Drop a PDF file here or click to upload Choose PDF Maximum file size: 10MB Principal Ophthamologist Name of Principal Ophthalmologist * Job Title * Email * Name of Institution * Address * EUGOGO Teaching Course Attended? * Yes No If yes specify which course * If yes upload certificate of attendance * Drop a PDF file here or click to upload Choose PDF 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 * Email * EUGOGO Teaching Course Attended? * YesNo If yes upload certificate of attendance * Drop a PDF file here or click to upload Choose PDF 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 Drop a file here or click to upload PDF Choose File 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 No If YES please list * Involvement in EUGOGO Projects Y/N * Yes No If YES please list * Recommendation by another EUGOGO Centre Y/N * Yes No If yes please upload letter of recommendation Drop a PDF file here or click to upload Choose PDF or docx Maximum file size: 10MB Case Studies Please upload 3 cases of complex GO patients managed at your centre from presentation to outcome that is representative of the case mix seen at your centre. Please include as much details of the Ophthalmic & Endocrine clinical presentation as possible but please ensure full anonymisation. Case study 1 * Drop a file here or click to upload PDF Choose File Maximum file size: 10MB Case study 2 * Drop a file here or click to upload PDF Choose File Maximum file size: 10MB Case study 3 * Drop a file here or click to upload PDF Choose File 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 * signature keyboard Clear Name * Email * Position * Institution * Date Submit If you are human, leave this field blank.
