1.Address

Name

Address

Address 2

City/Town

State/Province

Zip/Postal Code

Email Address

Cell Phone Number

2.Tell us about your current Abdominal ultrasound level so we can tailor our teaching and station to your needs

I am a beginner - I've barely done any scanning

I am intermediate - I get most organs, but struggle with adrenal glands and high end views

I am advanced - I readily get all organs but would like to improve my efficiency on high end views and clinical pathology

Other (please specify)

3.What brand is your ultrasound machine?

GE

Mindray

Siemans

Toshiba

Samsung

Phillips

Other (please specify)

4.Are you looking to upgrade your current ultrasound system?

Yes

No

I do not have an ultrasound machine

5.What do you hope to achieve from our 3 day ultrasound wet lab?

6.Do you have any dietary restrictions?

Yes

No

If yes (please specify)

7.Anything else you would like us to know?

8.What is your favorite drink that gets you on your game? (americano from Starbucks, Mountain Dew etc. You name it and we will have your specific drink ready for you each day)

9.If an ultrasound is performed in house, do you

Interpret in house

send case out for telemedicine report by a specialist

Other (please specify)