FSO Mentee Application Form

FSO Mentee Application Form

Please complete if you are interested in participating in the FSO Mentorship Program and being matched with an ophthalmologist.
Name

First NameLast Name
Degree
Institution/Practice
Years in Training
Estimated Graduation Year:
City, State
Email
example@example.com
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred method for your mentor to contact you:
Would you prefer your mentor be working in a specific area of ophthalmology? If so, list here:
Below is a list and description of our FSO Mentors:
1. Helayna Brown, MD – Jupiter, FL
  Practice: Michael L Levine, MD
  Areas of Specialty: cornea, cataract and refractive surgery
2. Basil K. Williams Jr., MD - Miami , FL
  Practice: Bascom Palmer Eye Institute
  Areas of Specialty: Vitreoretinal Surgery and Diseases, Ocular Oncology
3. Rishi P. Singh, MD, FASRS – Stuart, FL
  Practice: Cleveland Clinic Martin Hospitals, Cleveland Clinic Florida
  Areas of Specialty: Retina
4. Zelia M Correa, MD, PhD - Miami and Palm Beach Gardens, FL
  Practice: Bascom Palmer Eye Institute/Sylvester Comprehensive Cancer Center, University of Miami, Miller School of Medicine
  Areas of Specialty: ocular oncology, melanoma, intraocular tumor biopsy, animal models
5. Courtney Bovee , MD – Clearwater, FL
  Practice: Bovee Eye
  Areas of Specialty: Glaucoma, Anterior Segment Eye Conditions and Diseases
6. Matthew Kay, MD – Miami, FL
  Practice: Larkin Community Health Center
  Areas of Specialty: Neuro-ophthalmology
Please select and rank your top three choices from the list below. 1 = first choice; 2 = second choice; 3 = third choice. You must rank exactly three different individuals.
Please list any additional information you would like to share.
Should be Empty: