Professional Enrollment Form

Full Name*

Preferred Username* This will be your display name in the forums

Primary Specialty* Select Specialty Anesthesiology Cardiology Emergency Medicine Family Medicine Internal Medicine Neurosurgery Obstetrics & Gynecology Pediatrics General Surgery Other

Medical Credentials*

Medical License Number*

Hospital Affiliation*

Medical License Upload* Upload a clear photo or PDF of your current medical license. Accepted formats: PDF, JPG, PNG

Subspecialty Certificate (Optional) Upload subspecialty board certification if applicable. Accepted formats: PDF, JPG, PNG

Requested Forums (Select up to 2) Anesthesiology Cardiac Surgery Dental Anesthesia Dermatology Emergency Medicine Family Medicine General Surgery Internal Medicine Neurosurgery Obstetrics & Gynecology Orthopedic Surgery Pediatrics Podiatry Urology Cardiology Critical Care Medicine Endocrinology Gastroenterology Hematology Hospital Medicine Infectious Disease Nephrology Oncology Pulmonology Rheumatology Hold Ctrl (or Cmd on Mac) to select multiple forums. Maximum 2 selections allowed.