Perioperative Brain Health Initiative Call to Action
Fill in the fields below to agree to promote the AARP/ASA Perioperative Brain Health Initiative Call to Action to patients, providers, hospitals, regulatory agencies and funders.
Name
*
First Name
Last Name
Credentials
Institution
Email
*
example@example.com
Are you agreeing to promote the PBHI Call to Action on behalf of yourself or your institution?
*
Self
Institution
Both
I give permission to use my name as an individual signer of the PBHI Call to Action in future PBHI communications
*
Yes
No
I give permission to use my institution’s name as a signer of the PBHI Call to Action in future PBHI communications (By giving permission to list your institution’s name in future PBHI communications you attest that you have received any required approvals to do so.)
*
Yes
No
Submit
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