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SAGES Telementoring Study – Sleeve Gastrectomy Application

FAME Telementoring Study Application Form

Name*
First Last
Please enter your given and family name.
Date of Birth*
Year of Graduation from Medical School*
Please enter a value between 1900 and 2015.
FLS Accredited*
- Yes
- No
Hospital Director's Name*
Institution*
Is this a COE Institution / Hospital*
- Yes
- No
Institution Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone- Cell
Fax
Email*
Which of the following specialties best describes your clinical practice?*
Please check all that apply
- Bariatric Surgery only
- Bariatric and General Surgery
Is your center a Bariatric Center of Excelence?*
- Yes
- No
How many years have you been in practice?*
- 0-5 years
- 6-10 years
- 11-15 years
- >15 years
How long have you been performing Bariatric surgery?*
- 0-2 years
- 3-5 years
- 6-10 years
- 10 or more years
Average number of Bariatric cases per year?
How long have you been performing Sleeve Gastrectomy?
- 1-2 years
- 3-4 years
- 4-6 years
- 6 or more years
How many laparoscopic sleeve cases have you performed?
Do you currently have privilege in your hospital to perform lap sleeve gastrectomy?
- Yes
- No
If selected to participate, will you be able to have your hospital sign off on a liability indemnification for the proctor?
- Yes
- No
Location of your Practice
Hospital(s) where you have privilege to perform Bariatric surgery
Your training in General Surgery
Fellowship Training
Comments
This field is for validation purposes and should be left unchanged.

SAGES 2018 Meeting, Seattle, WA, April 11-14, 2018

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SAGES 2018 Annual MeetingApril 11th, 2018

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Society of American Gastrointestinal and Endoscopic Surgeons
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