Young Microsurgeon Group Membership Application

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* 1. Contact Information

Name

Email Address

Phone Number

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* 2. Year you started practice after training

Date

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* 3. Residency Program

Location

Graduation Year

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* 4. Microsurgery Fellowship

Location

Graduation Year

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* 5. Other Fellowships

Type

Location

Graduation Year

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* 6. Current Practice Location

City

State

Country

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* 7. Current Practice Type

Academic

Hospital Based

Private Practice

Other (please specify)

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* 8. Name of Institution / Hospital / Practice

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* 9. Please select any administrative roles you hold

Clerkship Director

Residency Program Director

Associate Residency Program Director

Fellowship Director

Other (please specify)

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* 10. Current Practice Mix

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* 11. I perform the following (click all that apply)

Head and Neck Reconstruction

Lower Extremity Reconstruction

Upper Extremity Reconstruction

Breast Reconstruction

Lymphedema Surgery

Gender Surgery

Other (please specify)

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* 12. The largest proportion of my microsurgical cases are the following

Head and Neck Reconstruction

Lower Extremity Reconstruction

Upper Extremity Reconstruction

Breast Reconstruction

Lymphedema Surgery

Gender Surgery

Other (please specify)

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* 13. Microsurgery cases per year

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* 14. Which of the following is true about your practice?

I am the only microsurgery-trained surgeon in my practice and perform microsurgical cases alone

I have microsurgery-trained partners and co-surgeon cases with them

I have microsurgery-trained partners but do not use a co-surgeon model

I use a co-surgeon model for microsurgical cases with non-microsurgical colleagues as co-surgeons

Other (please specify)

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* 15. As a group that intends to support and nurture young microsurgeons, we look for opportunities to showcase our members. If you are interested in giving presentations for YMG, please provide a short list of topics you'd be interested in presenting (maximum 5)

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* 1. Contact Information

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* 2. Year you started practice after training

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* 3. Residency Program

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* 4. Microsurgery Fellowship

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* 5. Other Fellowships

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* 6. Current Practice Location

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* 7. Current Practice Type

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* 8. Name of Institution / Hospital / Practice

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* 9. Please select any administrative roles you hold

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* 10. Current Practice Mix

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* 11. I perform the following (click all that apply)

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* 12. The largest proportion of my microsurgical cases are the following

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* 13. Microsurgery cases per year

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* 14. Which of the following is true about your practice?

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* 15. As a group that intends to support and nurture young microsurgeons, we look for opportunities to showcase our members. If you are interested in giving presentations for YMG, please provide a short list of topics you'd be interested in presenting (maximum 5)

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* 16. Please list your main areas of career interest

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* 17. ASRM Membership Status

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* 18. Why do you want to joint YMG?

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* 19. Gender

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* 20. Race Ethnicity