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Submit a guest for the vlmd rounds Podcast
Please submit guest suggestions for vlmd rounds using this form.
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Full Name
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Credentials
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Please select the person's credentials. If they have multiple credentials (e.g., MD & PhD), please select both choices. If their credentials are not listed below, choose "Other" and enter a comment.
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OD
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Organization/Institution
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What are this person's accomplishments?
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Website & Social Media Profiles
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Desired topic(s) of discussion
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What topic(s) would this person be interested in discussing with Dr. Loh?
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