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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
Name
This field is for validation purposes and should be left unchanged.

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

SAGES 2018 Meeting Information

The 2018 World Congress of Endoscopic Surgery hosted by SAGES and CAGS is happy to announce that our Final Program is now available for download. Final Program too big/too long? Download the Schedule at a Glance instead!

Online Registation is now available.

Countdown!

SAGES 2018 Annual MeetingApril 11, 2018

The big day is here.

SAGES News and Updates

Mastering the Art of Surgery – Annual Meeting Press Release

Complete the SAGES Video Based Assessment Survey for a Chance to Win!

See more SAGES News

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Name*
First Last
Email*
Name
This field is for validation purposes and should be left unchanged.

Important Links

SAGES 2018 Meeting Information

Our Advance Program is now available for download. Advance Program too big/too long? Download the Schedule at a Glance instead!

Online Registration is now available. . Please be sure to register before February 23, 2018 to obtain the early registration discount.

Healthy Sooner: Patient Information

Contact SAGES

Society of American Gastrointestinal and Endoscopic Surgeons
11300 W. Olympic Blvd Suite 600
Los Angeles, CA 90064 USA
webmaster@sages.org
Tel: (310) 437-0544

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