General Information

Full Name*

First NameLast Name

Credentials*

MD, DO, etc.

Professional E-mail*

example@example.com

Personal E-mail*

Please provide your personal email address so we can stay in contact with you after you move on from your program.

Cell Phone Number*

Preferred Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you attended HS Academy in the past?*

YesNo

Please indicate which year(s) you attended in the past.*

2021202220232024

Residency Program

Dermatology Training Year*

123

What is the name of your residency program?*

Is there an HS specialist at your program?*

YesNo

Who is the HS specialist at your program?*

In one sentence, why do you want to attend this event?*

Please wait to book your travel until after you receive your official invitation to attend from our staff.