Information Response Form | WDS Women Dermatologic Surgeons Committee

WOMEN’S DERMATOLOGIC SOCIETY
WDS Women Dermatologic Surgeons Committee Information Response Form

REQUEST FORM DATE:--

Your Name

E-Mail Address:

Address:

City:

State:

Zip:

Country:

Telephone:

Fax:

Type of Practice:

Private Practice
Academic
Still in Training

If in training, what is your expected completion date?

Areas of Interest:
(Check all that apply)

Mohs surgery
Cosmetic Surgery
Dermatologic Surgery
Laser Surgery
Other:

Would you like to be included in a WDS Women Dermatologic Surgeons Committee eMail ListServe?

Yes
No

Would you like your information to be made available in a Women Dermatologic Surgeons Committee section on the WDS website?

Yes
Yes, allowing the email address on the website for members only
Yes, but do not provide e-mail address on website for the public
No

Would you allow the printing of your information in the printed WDS Directory for members?

Yes, including my email address
Yes, without my email address
No, to any information being placed in the printed membership directory

ADDITIONAL COMMENTS:

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