Visiting surgeon interest form

Thank you for your interest in becoming an ACS VA Chapter visiting surgeon. The VA ACS will reach out to you with a prospective host institution or surgeon with expertise in your area of interest. You will be able to accept or reject an opportunity to visit, and you can make arrangements with the prospective host institution or surgeon regarding time and duration of stay. There is no obligation on either side to cover any costs and provide any reimbursement. Please provide the following information:

Name / Degree*

Name of institution / hospital / medical practice:*

Location (city):*

Phone

Email*

Division Chief / Department Chair / Section Chief (if applicable) Name *

Division Chief / Department Chair / Section Chief (if applicable) Email *

Areas of interest (1):*

Area of interest (2):

Area of interest (3):

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Virginia Chapter, American College of Surgeons

2821 Emerywood Parkway, Henrico, Virginia 23294, United States