ACD Mohs Scientists & Technicians Group

ACD Mohs Scientist & Technician Group

Please fill in the form below.
Full Name*

Prefix First Name Last Name
Address (for correspondence only)*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mobile Phone*

Area Code Phone Number
Work Phone

Area Code Phone Number
E-mail*
I identify my gender as:
Educational Qualifications:
How many places do you work as a Mohs Tech in a fortnight?*

1-23-4over 4not applicable
If you have ticked not applicable above please state why
Employment Information
Hospital(s)/Clinic(s) name where you currently work (please list all here)*
Number of contact hours working in each Mohs lab per fortnight*
Position(s) held*
Names of all Dermatologists you have worked with
Number of years total Mohs experience
Mohs S&T Executive
Are you interested in being a member of the Mohs S&T Executive Committee?*

YN
If yes please advise what you will be able to contribute to the group?
Mohs S&T Meeting at the ACD's Annual Scientific Meeting

Please indicate if you are interested in attending the Mohs S&T meeting next May 2020 taking place in Adelaide.

It is important that the next Mohs S&T meeting is arranged with the input of one or more Mohs Scientists/Techs, their Mohs surgeon and the College. Please indicate if you would be willing to contribute to the schedule i.e. recommending topics to be discussed and relevant speakers that you would like to hear
Are you interested in attending the Mohs S&T meeting next year in Adelaide?*

YN
What topics would you like to hear about at the meeting?
ACD Connect - Mohs S&T Online Community

As part of the ACD Mohs S&T group we are creating an online community. This is an space for Mohs S&T members to connect, ask question, share information and will be hosted and monitored by the ACD. Joining this will provide up to date information on latest events, education and quality assurance. Please indicate below if you would like to be added to this group using your email address.
Do you wish to be added to the Mohs S&T online community?*

YesNo
Please let us know what you would like to get out of the Mohs S&T group and how we can make this a valuable and useful community
Should be Empty:

ACD Mohs Scientist & Technician Group

Employment Information

Mohs S&T Executive