Sclerotherapy Training Services
Preceptorship Preliminary Application Form
Fax: 503-769-6466

Name:

Area of Specialty:

Day Phone:     Ext:

Evening Phone:

Fax:

Which telephone number is best to reach you?       DAY       EVENING

Preferred day to be contacted by phone:     MON     TUE     WED     THR     FRI     SAT     SUN

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?       M.D.       D.O.       R.N.       N.P.       F.N.P.       P.A.

Are you currently performing any sclerotherapy procedures in your practice?       YES       NO
        If YES, please describe
       

What is your level of Phlebology expertise?
        1. Little to None
        2. Beginning
        3. Intermediate
        4. Experienced

Which type(s) of preceptorship are you interested in?
Basic 2 1/2 Day Preceptorship
Extra Day(s) - Number of Days
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?