CASE REPORT APPLICATION FORM
34th Annual John R. Rainey, MD Abstract Competition
January 18 - 20, 2019
Hyatt Regency Lost Pines Resort; Bastrop, TX
Deadline to Submit: Friday, November 2, 2018

First Author Information

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* 1. First Name:

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* 2. Last Name:

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* 3. Credential(s):

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* 4. I am a...

Medical Student

Resident

Fellow

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* 5. Mailing Address:

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* 6. City:

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* 7. State:

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* 8. Zip Code:

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* 9. Phone Number: (XXX) XXX-XXXX

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* 10. Email Address:

Program Information

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* 11. Company/Institution:

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* 12. Program Director:

Case Report Information

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* 13. Category:

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* 14. Abstract Title:

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* 15. Additional Authors:

PLEASE NOTE! Total number of words for submission is 350. We have limited each question to 150 words, but your total number of words for your ENTIRE submission is 350.

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* 16. Introduction: (please limit to 150 words)

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* 17. Case Presentation: (please limit to 150 words)

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* 18. Pathologic and Ancillary Findings: (please limit to 150 words)

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* 19. Discussion: (please limit to 150 words)

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* 20. File Upload

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 21. Acknowledgements:

I must register to attend this year's Annual Meeting ($50).

The case report being submitted lists the individual above as the first author.

The case report being submitted represents the work performed by the first author listed above.

The case report being submitted has not been presented at prior national meetings.

That case report being submitted has been read and approved by my Program Director.

Author Initials: