Literary AMWA Writing Submission
Name
*
First Name
Last Name
E-mail
*
Phone Number
-
Area Code
Phone Number
Street Address
City, State, Zip Code
I am a(n)
Please Select
Physician-active
Physician-retired
Intern or Resident
Medical Student
Pre-medical Student
Other
Specialty (if applicable)
Affiliation (if any)
Title of Submission
Category of Submission
Please Select
Fiction
Nonfiction
Poetry
Writing must be original and unpublished, and patients must not be identifiable
*
I affirm that this is an original piece of writing that has not been published elsewhere. If this writing describes actual patients, all identifying characteristics have been removed.
Upload writing here (Microsoft Word format preferred)
*
Upload a File
Cancel
of
Patient Consent (choose one of the following)
*
All patients described in the writing have signed release forms available at www.amwa-doc.org/literary-amwa. I have attached the form(s) below.
Some or none of the patients described in the writing have signed consent forms.
No actual patients are described in the writing.
Signed Patient 1 Consent Form (if applicable)
Upload a File
Cancel
of
Signed Patient 2 Consent Form (if applicable)
Upload a File
Cancel
of
Additional comments, if any
Submit
Should be Empty: