We are looking for interested Surgeon Champions to present on either an upcoming monthly Surgeon Champion Call or during the Surgeon Champion Session(s) at the 2019 ACS Quality and Safety Conference. 

If you are a Surgeon Champion who would like to participate, or you know of a Surgeon Champion who may wish to participate, please complete the form below.

Thank you!

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* 1. What is the Surgeon Champion's name?

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* 2. What is the Surgeon Champion's email address?

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* 3. What is the Surgeon Champion's hospital(s)?

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* 4. What are the main areas/specialties of practice for the Surgeon Champion?

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* 5. What ACS Quality Program(s) does your site participate in?

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* 6. Select the preference in which they are interested in presenting with ACS.

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* 7. Select the topics they are interested in collaborating with ACS.

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* 8. If you have additional comments please provide them below.

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* 9. Referrer Name (if different from above):

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* 10. Referrer Email Address (if different from above):

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