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Special Interest Group
TRANSPLANT PSYCHIATRY


JOIN THE
TRANSPLANT PSYCHIATRY SPECIAL INTEREST GROUP

 
Fill out and submit the form below to join the Tranaplant Psychiatry Special Interest Group (SIG). Becoming a member of the SIG will allow you to post messages to the discussion group, receive message-board postings in an e-mail, and receive notices of the Transplant Psychiatry SIG newsletter. Except for aggregate information about the group's composition, your information will not be shared with any group outside the Academy of Psychosomatic Medicine.


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Please indicate if you are filling out this form to join the SIG as a new member or if you are submitting changed information:

New member
Changed information

First Name:    Middle:

Last Name:

Suffix (MD, PhD, etc.):

Affiliation (name of institution):

E-mail address:

Re-enter e-mail address:

Mailing address line 1:

Mailing address line 2:

City:

State/Province: Zip: Country:

Phone: Fax:

Are you a member of the Academy of Psychosomatic Medicine?

Yes    No

Please indicate the type of clinician you are (select one):

Physician
Psychologist
Physician's assistant, nurse practitioner
Nurse, transplant coordinator
Social worker
Other:

Are you involved in research or do you have a research interest?

Yes    No

If yes, what research?

Please indicate which of the following transplanted organs you are involved with:

Liver:   Yes No
Kidney:   Yes No
Heart:   Yes No
Lung:   Yes No
Pancreas:   Yes No
Intestine:   Yes No
Bone Marrow:   Yes No

Please check your preferred "subscription type" (you will be able to change this yourself at any time if you register for a free Google Account):

E-mail — receive each new post in an e-mail (default)
Digest — receive all new posts in a single e-mail each day
No E-mail — read posts on the Web archive

Comments:

 

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