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Young Microsurgeon Group Membership Application
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1.
Contact Information
(Required.)
Name
Email Address
Phone Number
*
2.
Year you started practice after training
(Required.)
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
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24
25
26
27
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31
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3.
Residency Program
(Required.)
Location
Graduation Year
4.
Microsurgery Fellowship
Location
Graduation Year
5.
Other Fellowships
Type
Location
Graduation Year
*
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.)
*
9.
Please select any administrative roles you hold
(Required.)
Clerkship Director
Residency Program Director
Associate Residency Program Director
Fellowship Director
Other (please specify)
*
10.
Current Practice Mix
(Required.)
100% Reconstructive
Mainly reconstruction, some cosmetic
50%/50% reconstructive and cosmetic
Mainly cosmetic, some reconstruction
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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.)
Less than 10 cases per year
10 - 30 cases per year
30 - 50 cases per year
50 - 70 cases per year
70 - 100 cases per year
>100 cases per year
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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)
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)
1.
2.
3.
4.
5.
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16.
Please list your main areas of career interest
(Required.)
1.
2.
3.
4.
5.
17.
ASRM Membership Status
Active
Associate
Candidate
18.
Why do you want to joint YMG?
19.
Gender
Cis - Male
Cis - Female
Trans - Male
Trans - Female
Non-binary / non-conforming
Prefer not to respond
20.
Race Ethnicity
African American
Caucasian
Hispanic
Asian
Other (please specify)
