Sclerotherapy Training Services

Preliminary Application Form

The first step in scheduling your Sclerotherapy Training Preceptorship is to complete this Preliminary Application Form. There is no obligation when sending us this form and no fees are required. Once we have received this form we will telephone you.

Please fill out the form below and click the [SUBMIT] button,
OR
Click here for a printable form to be faxed to 503-581-5351.

Name:

Area of Specialty:

Day Phone: Ext:

Evening Phone:

Fax:

Email:

Which telephone number is best to reach you?

Preferred day to be contacted by phone:

Preferred time to be contacted by phone:

Mailing Address:

If you either work for another physician or will be sponsored by another person after completion of your preceptorship please provide that person's name with professional degree, address and day time phone number(s). If none, leave blank.

I will be sponsored by:

Name:

Address:

Business Phone:

Fax:

So we might determine the best type of preceptorship for you, please provide some professional information about yourself. All information will be held in strict confidence.

What is you professional degree?

Are you currently performing any sclerotherapy procedures in your practice?

If yes, please describe

What is your level of Phlebology expertise?

Which type(s) of preceptorship are you interested in?
Basic 3 Day Preceptorship
Specialty Preceptorship - must have been either attended a preceptorship with us before or one of our Sclerotherapy Training Workshops

What are your goals for this preceptorship? What do you hope to learn? What are your long term goals for sclerotherapy?