Enrollment Form 2014-2015

Charles University in Prague, Faculty of Medicine in Pilsen
ENROLLMENT FORM-2014/2015
General Medicine 6
th
year
SRN!ME
Fir"t na#e

Middle na#e"
$ate %& 'irth ($ )*a""+%rt, N%-
T%.n/c%/ntry Nati%nality
%& 0irth
Your address abroad:

Telephone:
Fax No : !ail:
"ddress in C#ech $epublic:

Telephone:
!ail:
General Medicine 6
th
year
ENROLLE$ S'1E2TS
Mini#/# N%- %& E2 &%r enr%ll#ent in the 6th year - 235
S'1E2TS
No% of hours per &ee' (lectures)practicals*
&inter se!ester No%of C
+% ,nternal Medicine +- &ee's 16
.% /bstetrics and 0ynecology 1 &ee's 10
2% Pediatrics . &ee's 10
1% 3ocial Medicine and Public 4ealth 2 &ee's 4
5% 3urgery 6 &ee's 16
O5er.r%/6ht "/07ect" / (ndi5id/al "t/dy +lan
Tuition fee pay!ent: 777777 (date*
S(GN!TRE --------------------------------------------------------
F/$ /FF,C,"8 U3:
9atu! #:pisu:
Platba ; +* datu! <:st'a
.* datu! <:st'a
Po#n:!'y:
0eneral Medicine ; 5
th
year
3U$N"M
First na!e

Middle na!es
9ate of =irth ,9 (Passport* No%
To&n)country Nationality
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:
General Medicine 5
th
year
ENROLLE$ S'1E2TS
S'1E2TS
No% of C
+% "nesthesiology and $esuscitation 6 C, 4
.% Clinical =ioche!istry > C, 2
2% Clinical /ncology >C 1
1% ar, Nose and Throat 9iseases 6 C, 4
5% pide!iology > C, 2
>% ,nfectious 9iseases 6 C, 4
?% ,nternal Medicine >C 2
@% Medical 0enetics 2C 1
6% Neonatology 5 C 2
+-% /bstetrics and 0ynecology +. C 8
++% /phthal!ology 6 C, 4
+.% /rtopedics and Trau!atology +. C, 5
+2% Pediatrics +- C 6
+1% Psychiatry +. C, 5
+5% Public 4ealth >C 1
+>% 3ocial Medicine and =iostatistics > C 1
+?% 3pecial Fields of ,nternal Med% >C 2
+@% 3urgery 2- C 2
3 A C 5
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F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
th
year
3U$N"M
First na!e

Middle na!es
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:
General Medicine 4
th
year
ENROLLE$ S'1E2TS
S'1E2TS
&inter)su!!er se!ester No%of%C
+% 9er!atovenerology +)2 C, 4
.% Forensic Pathology > C, 9
2% ,nternal Medicine .)2 C .)2 C 4
1% Neurology +). C +). C, 3
5 Phar!acology 1). C, 3
>% Propedeutics of 3urgery .). C, 4
?% $adiology and Nuclear Med% +)+ C +)+ C, 4
@% 3ports Medicine +)+ C 1
6% 3to!atology +)+ C, 2
+-% 3urgery .)2 C 9
++% 3P ,nternal Medicine . &ee's 9
+.% 3P 3urgery . &ee's 9
+2% Urology +)- C +)+C, 9
3: 4
O5er.r%/6ht "/07ect" / (ndi5id/al St/dy *lan
S(GN!TRE --------------------------------------------------------
F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
rd
year
3U$N"M
First na!e

Middle na!es
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:
General Medicine 9
rd
year
ENROLLE$ S'1E2TS
Mini#/# N%- %& E2 &%r enr%ll#ent in the 9rd year 34
S'1E2TS
&inter)su!!er se!ester
No% of CB
+% ,!!unology .)- C, 9
.% ,nternal Medicine .)2 C 9
2% Medical Psychology +)+ C +). C, 5
1% Microbiology .)- C, 5
5% Pathological Physiology .)2 C 2)1 C, 19
>% Pathology 5)2 C 1)2 C, 18
?% Phar!acology +). C 9
@% Prop% of ,nternal Medicine 2)1 C, 6
3: 5
S(GN!TRE --------------------------------------------------------

F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
0eneral Medicine ; .
nd
year
3U$N"M
First na!e

Middle na!es
of birth
Your C#ech C,3" expires on %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
Telephone:
Fax No : !ail:

Telephone:
!ail:
General Medicine 2
nd
year
ENROLLE$ S'1E2TS
Mini#/# N%- %& E2 &%r enr%ll#ent in the 2nd year 40
S'1E2TS
&inter) su!!er se!ester
No% of C
+% =ioche!istry .)1 C 1)1 C, 14
.% C#ech for Foreigners -)1 C -)1 C, 9
2% 4istology and !bryology .)2 C, 6
1% Physiology 1)1 C >)5 C, 22
5% Topographical "nato!y .)1 C, 6
>% 3P A Nursing 2 &ee's C 9
?% Microbiology -). C 2
3: 4
3,0N"TU$ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
9entistry ; .
nd
year
3U$N"M
First na!e

Middle na!es
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:
$enti"try Medicine 2
nd
year
ENROLLE$ S'1E2TS
Mini#/# N%- %& E2 &%r enr%ll#ent in the 2nd year - 42
S'1E2TS
&inter) su!!er se!ester
No% of C
+% =ioche!istry .)+,5 C, 6
.% =iology and 0enetics .). C, 5
2% Clinical 9entistry -). C 2
1% C#ech for Foreigners -)1 C -)1 C, 1
5% 4istology and !bryology +). C, 9
>% Pathology and /ral Pathology .). C 9
?% Physiology 2)2 C 2)2 C, 16
@% Preclinical 9entistry .)1 C .)+ C, 12
6% Preventive 9entistry .)- C 0
+-% Prothetic Technology +)5 C, 2
++% Psychology and Co!!% &ith patient -)+ C 1
+.% 3u!!er Practice + &ee' 1
+2% Top% "nato!y of the 4ead and Nec' +). C, 9
ES: 5
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F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
9entistry ; 2
rd
year
3U$N"M
First na!e

Middle na!es
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:
$enti"try 9
rd
year
ENROLLE$ S'1E2TS
Mini#/# N%- %& E2 &%r enr%ll#ent in the 9rd year - 104
S'1E2TS
&inter)su!!er se!ester
No% of C
+% Clinical 9entistry -)> C -)> C 10
.% Conservative 9entistry and ndodontics +)- +)- -
2% 9ental $adiology +)+ C, 6
5% ,!!unology -)+ C, 2
>% ,nternal Medicine 2). C 4
?% Microbiology .). C, 9
@% /ral and Maxillofacial 3urgery +)- +)- -
6% /ral =iology +)- C, 2
+-% Pathological Physiology .). C, 8
++% Pathology and /ral Pathology .).C, 10
+.% Phar!acology .)+ C .)+ C, 6
+2% Prosthodontics +)- +)- -
+1% Psychiatry +)+C, 9
+5% 3u!!er Practice . &ee's 2
ES: 5
S(GN!TRE --------------------------------------------------------

F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
9entistry ; 1
th
year
3U$N"M
First na!e

Middle na!es
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:
$enti"try 4
th
year
ENROLLE$ S'1E2TS
S'1E2TS
&inter)su!!er se!ester No% of C
+% 3urgery .). C .). C 4
.% ,nternal Medicine .). C .). C, 9
2% ,nfectious 9iseases and pide!iology +)+ C, 2
1% Neurology +)+ C, 9
5% /phtal!ology +)+ C, 2
>% Clinical 9entistry -)+. C -)+@ C 3
?% Prosthodontics +)- +)- C, 6
@% /ral and Maxillofacial 3urgery +)- +)- C, 8
6% Conservative 9% and ndodontics +)- C, 4
+-% /rthodontics +)- +)- 0
++% Pediatric 9entistry .)- 0
+.% Pediatrics +)+ C, 4
+2% /bstetrics and 0ynecology +)+ C, 2
+1% Paronontology +)- C, 9
+5% 3to!atological Practice 1 &ee's 2
+>% 9er!atovenereology +)2 C, 9
ES: 5
O5er.r%/6ht "/07ect" / (ndi5id/al St/dy +lan
S(GN!TRE --------------------------------------------------------
F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a
9entistry ; 5
th
year
3U$N"M
First na!e

Middle na!es
of birth
Telephone:
Fax No : !ail:

Telephone:
!ail:

$enti"try 5
th
year
ENROLLE$ S'1E2TS
S'1E2TS
&inter)su!!er se!ester No% of C
+% "nesthesiology +)+ C, 4
.% 3urgery +). C, 6
2% Manage!ent in 9entistry -)+ C 1
1% ar, Nose and Throat 9iseases .)+ C, 4
5% Public 4ealth Medicine +)+ 2
>% /ral 4ealth Medicine +)+ C 2
?% Clinical 9entistry -)+@ C .)> C 10
@% Parodontology -). 3 5
6% Prosthodontics +). 3 5
+-% Pediatric 9entistry -)+. C -). 3 5
++% /ral and Maxillofacial 3urgery 2)- -). 3 5
+.% /rthodontics -). 3 5
+2% Conser% 9entistry and ndodontics -). 3 5
+1% Forensic 9entistry -,5)-,5 C, 1
S(GN!TRE --------------------------------------------------------
F/$ /FF,C,"8 U3:
9atu! #:pisu:
.* datu! <:st'a

Enrollment Form 2014-2015

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Charles University in Prague, Faculty of Medicine in Pilsen

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