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  • Application VVP

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    Anonymous AuJncFVWv
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    The document is an application for the Visiting Physicians Program at House Clinic located at 2100 W. 3rd Street in Los Angeles. It requests contact information, dates of visit, accommodations, areas of medical interest, and profession of the applicant. The contact at House Clinic for the program is Miriam Maldonado.

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    Application Vvp (2)

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    The document is an application for the Visiting Physicians Program at House Clinic located at 2100 W. 3rd Street in Los Angeles. It requests contact information, dates of visit, accommodations, areas of medical interest, and profession of the applicant. The contact at House Clinic for the program is Miriam Maldonado.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Download as docx, pdf, or txt
    73 views1 page

    Application VVP

    Uploaded by

    Anonymous AuJncFVWv
    The document is an application for the Visiting Physicians Program at House Clinic located at 2100 W. 3rd Street in Los Angeles. It requests contact information, dates of visit, accommodations, areas of medical interest, and profession of the applicant. The contact at House Clinic for the program is Miriam Maldonado.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 1

    2100 W.

    3rd Street
    Los Angeles, CA 90057
    (213) 273-8089
    VPP Contact: Miriam Maldonado
    mmaldonado@houseclinic.com

    VISITING PHYSICIANS PROGRAM APPLICATION


    Please print clearly
    Name: _______________________________________________________________________________________
    Last
    First
    Suffix
    Gender
    Title or Degree: ________________________________________________________________________________
    Home Address: ________________________________________________________________________________
    City: ____________________________State:__________________ Country: ________________ Zip: __________
    Home Phone: _____________________ Cell: _____________________ Email: _____________________________

    ______________________________________________________________________
    Business Institution or Affiliation: ___________________________________________________________________
    Business address: ______________________________________________________________________________
    City: ____________________________State:__________________ Country: ________________ Zip: __________
    Phone: _______________________ Fax: _______________________ Email: ______________________________

    ______________________________________________________________________
    Have you ever visited us before? Yes__________ No__________
    Arrival Date: _________________________________

    Departure Date: _________________________________

    Where will you be staying while in Los Angeles? ______________________________________________________


    Contact Numbers while in Los Angeles: _____________________________________________________________
    Can you speak conversational English? _____________________________________________________________
    Please indicate your specific interests while here at House Clinic _________________________________________

    ______________________________________________________________________
    What is your current profession?
    ____Otolaryngologist, M.D.
    ____Other Physician, M.D.
    ____Neurosurgeon, M.D.
    ____Audiologist

    ____Educator
    ____Speech Language pathologist
    ____Patient/Patients Family
    ____Other (please specify)____________________________

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