Visiting Rotation Form

Name Name First Last
Age
Gender

Gender Male Female Other
Email
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Current residency program
Clinical PGY level
Anticipated graduation date from residency
How did you hear about this opportunity?
If you are currently in a foreign residency program, please list what faculty member recommended this program to you. Please enter N/A(If not applicable).
What rotation are you interested in?

What rotation are you interested in? Maternal-Fetal Medicine Minimally Invasive Gynecologic Surgery Reproductive Endocrinology & Infertility
What is/are your preferred dates to rotate with us? Please list your first, second, third and fourth choices, including the start and end dates. All rotations are limited to 4 weeks. If you are flexible, indicate "Any available time is fine."
Do you have specific objectives and/or goals you would like to achieve during your rotation?
Why do you want to do this rotation at Eastern Virginia Medical School at Old Dominion University?

Why do you want to do this rotation at Eastern Virginia Medical School at Old Dominion University? This specialty is not offered at my home institution. I am considering a fellowship in this specialty. I would like the opportunity to work with a member of your faculty. I am trying to meet ACGME/ABOG case requirements. Other Other
If you're interested in working with a member of our faculty, please specify the professor below.
If you are trying to meet ACGME/ABOG case requirements , please specify cases below:
Please upload your CV

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