Young Microsurgeon Group Membership Application

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1. Contact Information (Required.)

Name

Email Address

Phone Number

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2. Year you started practice after training (Required.)

Date

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3. Residency Program (Required.)

Location

Graduation Year

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4. Microsurgery Fellowship

Location

Graduation Year

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5. Other Fellowships

Type

Location

Graduation Year

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6. Current Practice Location (Required.)

City

State

Country

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7. Current Practice Type (Required.)

Academic

Hospital Based

Private Practice

Other (please specify)

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8. Name of Institution / Hospital / Practice (Required.)

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9. Please select any administrative roles you hold (Required.)

Clerkship Director

Residency Program Director

Associate Residency Program Director

Fellowship Director

Other (please specify)

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10. Current Practice Mix (Required.)

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11. I perform the following (click all that apply) (Required.)

Head and Neck Reconstruction

Lower Extremity Reconstruction

Upper Extremity Reconstruction

Breast Reconstruction

Lymphedema Surgery

Gender Surgery

Other (please specify)

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12. The largest proportion of my microsurgical cases are the following (Required.)

Head and Neck Reconstruction

Lower Extremity Reconstruction

Upper Extremity Reconstruction

Breast Reconstruction

Lymphedema Surgery

Gender Surgery

Other (please specify)

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13. Microsurgery cases per year (Required.)

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14. Which of the following is true about your practice? (Required.)

I am the only microsurgery-trained surgeon in my practice and perform microsurgical cases alone

I have microsurgery-trained partners and co-surgeon cases with them

I have microsurgery-trained partners but do not use a co-surgeon model

I use a co-surgeon model for microsurgical cases with non-microsurgical colleagues as co-surgeons

Other (please specify)

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15. As a group that intends to support and nurture young microsurgeons, we look for opportunities to showcase our members. If you are interested in giving presentations for YMG, please provide a short list of topics you'd be interested in presenting (maximum 5)

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* 1. Contact Information (Required.)

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* 2. Year you started practice after training (Required.)

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* 3. Residency Program (Required.)

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* 4. Microsurgery Fellowship

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* 5. Other Fellowships

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* 6. Current Practice Location (Required.)

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* 7. Current Practice Type (Required.)

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* 8. Name of Institution / Hospital / Practice (Required.)

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* 9. Please select any administrative roles you hold (Required.)

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* 10. Current Practice Mix (Required.)

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* 11. I perform the following (click all that apply) (Required.)

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* 12. The largest proportion of my microsurgical cases are the following (Required.)

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* 13. Microsurgery cases per year (Required.)

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* 14. Which of the following is true about your practice? (Required.)

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* 15. As a group that intends to support and nurture young microsurgeons, we look for opportunities to showcase our members. If you are interested in giving presentations for YMG, please provide a short list of topics you'd be interested in presenting (maximum 5)

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* 16. Please list your main areas of career interest (Required.)

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* 17. ASRM Membership Status

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* 18. Why do you want to joint YMG?

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* 19. Gender

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* 20. Race Ethnicity

1. Contact Information (Required.)

2. Year you started practice after training (Required.)

3. Residency Program (Required.)

4. Microsurgery Fellowship

5. Other Fellowships

6. Current Practice Location (Required.)

7. Current Practice Type (Required.)

8. Name of Institution / Hospital / Practice (Required.)

9. Please select any administrative roles you hold (Required.)

10. Current Practice Mix (Required.)

11. I perform the following (click all that apply) (Required.)

12. The largest proportion of my microsurgical cases are the following (Required.)

13. Microsurgery cases per year (Required.)

14. Which of the following is true about your practice? (Required.)

15. As a group that intends to support and nurture young microsurgeons, we look for opportunities to showcase our members. If you are interested in giving presentations for YMG, please provide a short list of topics you'd be interested in presenting (maximum 5)

16. Please list your main areas of career interest (Required.)

17. ASRM Membership Status

18. Why do you want to joint YMG?

19. Gender

20. Race Ethnicity