SouthAsianHealth Membership Form

SouthAsianHealth Membership Form
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number
Please enter a valid phone number.
Current Practice Location (City, State/Province, Country)*
Primary Medical Specialty*
Subspecialty (if applicable)
How many years have you been practicing medicine?*
Practice Setting*

Solo PracticeGroup PracticeHospital-BasedAcademic/TeachingCommunity Health CenterTelemedicineOther
Languages Spoken in Practice

EnglishHindiUrduPunjabiBengaliGujaratiTamilTeluguMarathiOther
What are your main pain points or challenges in your current medical practice? (Select all that apply)*

Administrative burdenBilling and insurance issuesPatient engagement/communicationTechnology/EHR systemsWork-life balanceAccess to resourcesLanguage/cultural barriersSocial media presenceProfessional isolationOther
What do you love most about practicing medicine?*
What improvements or services would help you deliver better care or improve your practice? (e.g., administrative support, billing help, social media training, public health initiatives, technology upgrades, networking opportunities, etc.)*
Are you interested in participating in any of the following? (Select all that apply)

Mentorship programsContinuing medical education (CME)Networking eventsAdvocacy/public health campaignsResearch collaborationsLeadership opportunitiesOther
Do you have suggestions for new programs, services, or resources that would benefit South Asian Health physicians or the community?
Website
You did not enter a website

I don't have oneI need a new oneIts a corporate websiteOther
Do you use social media for professional purposes?

YesNo
Which of the following

InstagramTikTokFacebookGoogleLinkedinOther
How do you manage your Social Media

SelfStaffSocial Media ManagerI need helpOther
Please share any additional comments or information that would help us support you and the South Asian Health community.
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