Externship Program Mentor Sign-Up Form
Want to help prepare the next generation of plastic surgeons and researchers for a career in aesthetics? Sign up to be a mentor in The Aesthetic Foundation's Externship Program! As a mentor, we work to match you with an Extern in your area for a year-long virtual mentorship, which includes a 5-day observership in your practice or office.
Full Name (example: Jill Smith, MD)
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Office Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Provide a short biography and description of your practice.
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Outline what a medical student can expect to learn from a week-long observation of your practice.
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If contacted by The Aesthetic Foundation staff, I agree to provide them with an update after a medical student(s) visits my practice.
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Agree
I will inform my insurance carrier prior to medical student visits to my practice and follow their advice.
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Agree
Are you involved in aesthetic surgery research and interested in mentoring students in research as well?
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Yes
No
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Research Details
This will assist the team in matching you with students based on their interests.
Select your area(s) of expertise in aesthetic surgery research. Check all that apply.
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Facial Plastic Surgery
Breast Surgery
Body Contouring
Reconstructive Surgery
Energy Based Devices
Other
Are you currently affiliated with an academic institution?
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Yes
No
Do you have the ability to submit an IRB for your team?
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Yes
No
If yes, what academic institution and/or central IRB?
How many students are you willing to have for a given research project?
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2
3
4
Other
Are any of the following skillsets necessary for your mentee(s) to assist with your research efforts? Check all that apply.
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Statistics
Manuscript Writing
Medical Illustrations
Data Cleaning
N/A
Other
Any questions, comments, and/or concerns?
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You have successfully provided all necessary information. Please click "Submit" to complete the process.
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