HCP Consulting Nomination Form
Submit this form to request engagement of a Healthcare Professional for educational, advisory, or collaborative activities. All information will be reviewed by Medical Affairs.
Date of Submission
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
Title
Medical Specialty
*
Please Select
Electrophysiologist
General Cardiologist
Heart Failure Specialist
Primary Care Physician
Interventional Cardiologist
Sleep Specialist
Allied Healthcare Provider
Other
If other please specify
Years in practice (including Fellowship specialty)
Preferred method of communication
Please Select
Email
Text
Phonecall
Email
*
example@example.com
Mobile/Cell number
*
Select proposed HCP engagement type:
*
Speaker Program / Faculty
Conference Education (national programs)
Advisory Board / Advisory Council
Consultant (Product Marketing)
Which audience(s) would this speaker be most appropriate for?
Fellows
Allied Health Professionals
Cardiology
Electrophysiology
Primary Care Physicians
Emergency Room Physicians
Does the HCP have the ability to travel?
Please Select
Yes / restricted (Notice required)
Yes / unrestricted
No
Please upload CV / Resume here
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