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Interest Form
Please let us know what clinic(s) you are thinking about attending (Spring, Summer, and/or Fall) and if you have questions.
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Email
*
Your email
Name
*
Your answer
City, State (and country if not in the United States)
*
Your answer
Phone number
Your answer
Which clinics are you interested in attending? (please enter the year on "other"
*
Spring Eye/Dental (Usually March or April)
Summer Eye/Dental (Usually June or July)
Fall Eye/Dental (October)
Plastic Surgery
None
Other:
Required
Are you a medical professional? If so, what kind ?
*
NOT A MEDICAL PROFESSIONAL
Optometrist
Optician
Optometric technician
Ophthalmologist (cataract surgeon)
Surgical scrub tech
Sterile Processing Technician
Dentist
Dental hygienist or assistant
Pharmacist
Gynecologist
General Medicine
Pediatrician
Dermatologist
Plastic surgeon
Other:
Required
If you a medical professional? If so, how many years have you been practicing?
*
NOT A MEDICAL PROFESSIONAL
First year
2-5
6-8
Over 8
Currently Retired
Are you currently a student in optometry, dental or medical school? If so, which school, what year are you in , and what month/year do you expect to graduate?
Your answer
Which of the following languages do you speak?
English
Spanish
German
Are you a member of any organizations or professional groups? (Rotary, Lions, VOSH, SVOSH, etc.)
Your answer
Do you have any specific questions?
Your answer
Would you like to be contacted? If so, when is the best time and would you prefer to be contacted by phone or email?
Your answer
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