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Demographics Information

Please complete the form below to sign up to become a reviewer for medication safety projects.
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Title:
* First Name
MI
* Last Name
Degree/License/Certification
* Type of Professional Other
* Primary Practice Site Other
* Organization
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* Address Please note the address where Med-ERRS should send the honorarium for participation.
Line 2
* City
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* Work Phone
Fax
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Comments
Secondary Practice Site
Academic
Hospital
Long Term Care  
Managed Care
Home Care
Community
Healthcare Organization
Other
Area of Specialty
Anesthesia
Cardiology
Critical Care
Dermatology
Family Practice
Gastroenterology
Area of Specialty
Hematology/Oncology
Infectious Disease
Internal Medicine
Neurology
Neurosurgery
OB/GYN
Area of Specialty
Orthopedics
Pediatrics
Psychiatry
Surgery
Urology
Other