Prostate Fellowship Application

ABS Prostate Workshop – October 15–18 at the JW Marriott, Palm Desert | 10 Scholarships are available

You may attend the GYN portion of the workshop as well but mandatory attendance is required for the Prostate portion. Registration is complimentary. For more details of the stipend, please contact Melissa Pomerene at mpomerene
Name*

First NameMiddle NameLast Name
Institution/Practice*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Country
E-mail*
Alternate Email
example@example.com
Phone/Mobile Number*

Area CodePhone Number
Residency Institution
Residency Completion

MonthDayYear
Date
Type of Practice
Prostate - LDR
How many Prostate LDR cases have you performed:

None1-1011- 5051-100101+
How many Prostate LDR cases have you observed:

None1-1011-5051-100101+
LDR Technique(s) used:

Pre-planned/Pre-Loaded NeedlesMick applicator and Real Time OR Planning
Will you be doing Prostate LDR and/or HDR in your new practice

LDRHDRBoth
Do you need to obtain equipment

YesNo
Time interval to start implant program

None1-3 Months3-6 Months6-12 Months
Prostate - HDR
How many Prostate HDR cases have you observed:

None1-1011-5051-100101+
How many Prostate HDR cases have you performed:

None1-1011- 5051-100101+
HDR Technique(s) used:

Ultrasound based planningCT-based planning
Time interval to start implant program

None1-3 Months3-6 Months6-12 Months
GYN
How many GYN intracavitary cases have you observed:

None1-1011-5051-100101+
How many GYN intact cervical cases have you performed:

None1-1011-5051-100101+
HDR Technique(s) used:

Ultrasound-based planningCT-based planningCT/MR-based planning
How many GYN interstitial cases have you observed:

None1-1011-5051-100101+
How many GYN interstitial cases have you performed:

None1-1011-5051-100101+
HDR techniques used:

Ultrasound based planningCT-based planningCT/MR-based planning
Will you be doing GYN HDR in your new practice:

YesNoOther
Time interval to start implant program:

1-3 Months3-6 Months6-12 MonthsNA
Is your institution and/or administration supportive of brachytherapy?

YesNoNeed convincing
Tell us why you would like to attend the Workshop:
Additional Comments:
You may attend the GYN portion of the workshop as well but mandatory attendance is required for the Prostate portion. Registration is complimentary. For more details of the stipend, please contact Melissa Pomerene at mpomerene@virtualinc.com
Upload your CV, and support letter from your resident director.

Browse Files

Cancelof
Signature: by signing this i understand that i can attend the GYN portion but mandatory attendance is required for the Prostate portion of the Workshop
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ABS Prostate Workshop – October 15–18 at the JW Marriott, Palm Desert | 10 Scholarships are available

Prostate - LDR

Prostate - HDR

GYN