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Last Name
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First Name
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Your answer
Email for group (this address must be linked to a Google account)
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Your answer
Preferred email for personal communication (if different)
Your answer
Location (and nearest major town)
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Your answer
State/Province
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Your answer
Country
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Your answer
MAOI user accepting referrals
Yes
No
Contact Phone (Patient Referrals)
Your answer
Contact email (Patient Referrals)
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Qualification and practice (clinician, clinical researcher, non-clinical research) Pt/t, f/t etc)
*
Your answer
Position and practice
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Professor
Medical Doctor
Consultant
Director/Chair
Researcher/Scientist
Retired
Select all applicable
Professor
Medical Doctor
Consultant
Director/Chair
Researcher/Scientist
Retired
Select all applicable
Institution, Hospital etc.
Your answer
Areas of special interest
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Your answer
Decades of experience early/mid/late, semi-rtd, rtd)
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