2022 IUGA Video Competition Submission Form

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for Fellows, Trainees & Early Career Professionals

Video title *

Name *

Position *

Years of work experience in this position *

Affiliation (department, institution) *

Address *

E-mail *

Patient consent *

Yes. I have obtained consent from any patient whose history, exam, images may be used in this video. Materials in this video do not include patient identifiers such as names, dates, medical record numbers etc. You may be asked to show the completed consent form.

No/Not Applicable

Required

Summary of video content (max. word count 250) *

Submit

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