EMS Research : Registration Panels

General

General

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Thank you for taking the time to register as a specialist respondent.
We assure you that we will contact you only to invite you to participate in research with us and not for any selling or promotion.

Physician Registration Panel
Title:
First name: *required
Last name: *required
Gender: *required
Year of residency completion: *required
Hospital name: *required
Address 1: If you want to have your payment posted
Address 2: please provide Address, City and Postcode.
City: *required
Post Code: *required
Country: *required
Mobile number: *
Work number: *
Home Phone Number: * (at least one of the fields marked with * is required)
Email address: * (our preferred method of contact is email as it is least intrusive)
Fax number: *
Preferred time of contact: *required
Preferred method of contact:

- Work Phone
- Mobile
- Post
- Email
- Fax
- Home Phone
- N/A

Preferred day of contact: *required

How would you prefer to receive payments: Cheque: Bank transfer: (we will contact you separately for bank information)

Your grade:

What is your primary specialty?: *required
What is your sub-specialty, if any: *optional

Area of special interest: *optional

Year qualified as Specialist: *required

Are you affiliated to a teaching hospital, an active member of a medical association, or committee or anything else that is not mentioned here?

If so, please give the details: *optional

How many patients under your care do you
treat in a typical month?: *required

How many prescriptions do you
administer in a typical month?: *required

Are there any medications that you prescribe
more than others on a regular basis?: *required

Are you part of any committee or work group?
Please explain: *required

Secretary Name (if any): *optional
Secretary Contact Number (if any): *optional

Secretary Email Address (if any): *optional

Who do you consider to be the opinion
leaders in your field?

Name1: *optional
Hospital: *optional
Name2: *optional
Hospital: *optional