HHP Network

Name (Last):

Name (First):

Name (Middle):

Medical Degree:

Date of Birth:

Gender:

male

female

Languages Spoken:

Citizenship:

Type of care?

Primary Care Type :

Specialty Care Type :

Practice Address/Street:

City/State/Zip:

County:

Country:

Office Phone:

Cell Phone:

Office Fax:

Office Hours:

Office Email:

CLINICAL EDUCATION

Degree(s) obtained:

University:

City/State:

Degree:

OTHER DEGREED GRADUATE LEVEL EDUCATION

Degree(s) obtained:

Institution:

City/State:

Dates (from/to):

ADDITIONAL QUALIFICATIONS/TRAINING/FELLOWSHIPS

List below any additional training, fellowships and places of practice, including medical military services, subspecialty training programs, or public health.

My profile as submitted contains detailed and specific information relating to my professional position in the medical industry, and I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand that misrepresentation will be grounds for membership termination. In addition to membership termination, the user's profile on HHP shall be marked to indicate that membership has been terminated because of misrepresentation.

I release HHP its representatives, and any individuals or entities providing information to me from liability for any act, liability for medical/clinical outcomes or omission related to the evaluation, consultation or of a patient.

Agreed by:

Full Name:

Degree:

Date: