Ask the Expert - Case Study

Please fill out this form for the "Ask the Expert" small group sessions during the 2018 Vascular Annual Meeting.

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* 1. Full Name

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* 2. Email Address

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* 3. Please select which of the "Ask the Expert" series you wish to submit a case study for. If you'd like to submit more than one case studies, please complete this form for each one you'd like to submit.

Coding - Sean Roddy, MD; William Shutze, MD

Aortic Care fro Occlusive Disease - Daniel Clair, MD; John Eidt, MD; Chris Smolock; MD

Hemodialysis - Ellen Dillavou, MD; David Cull, MD

PAD - Sean Lyden, MD

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* 4. Please use the space below to briefly describe the case you wish to ask the expert:

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* 5. Use the space below to provide a brief history and physical exam for the patient:

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* 6. Use the space below to describe any additional issues you want to discuss during the program:

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* 7. Use the space below to describe the results you had:

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* 8. Use the space below to outline the questions you have for the moderator:

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* 9. Please upload any images or films related to this case.

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

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* 10. I hereby acknowledge that if my case is selected to be presented during the "Ask the Expert" series, I must be present during the session.

Yes