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First Name
Last Name:
Title:
Facility:
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Mailing Address 2:
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I. NEWSLETTER TOPICS
OPCT Weekly e-News
OPCT From The Floor
 

II. YOUR PRIMARY RESPONSIBILITY (choose one)
President/CEO/Owner
Administrator/General Manager
Medical Director
Staff Physician
Business/Office Manager
Clinic/Facility Manager
 Purchasing/Materials Mgr.
Nurse Supervisor/Manager
Technical Staff
Lab. Director/Manager/Staff
O/P Services Director
Other 

III. YOUR FACILITY'S SPECIALTIES (Check ALL that apply)
Anesthesiology
Diagnostic Radiology
Gastroenterology
General Practice/Family Medicine
Internal Medicine
Obstetrics/Gynecology
Oncology/Hematology
Orthopedics
Pathology
Radiation Oncology
Radiology
Surgery
Urology
Other

IV. HOSPITAL BED SIZE

V. PLANNING NEW CONSTRUCTION? (choose one)
1. New Facility/Construction 2. Expansion/Remodeling/Renovation 3. None

VI. TYPE OF FACILITY? (choose one)

 
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