| Member Registration |
ABOUT PHYSICIANS’ RESEARCH NETWORK
PRN’s mission is to provide ongoing peer support to physicians, nurse practitioners and physician assistants providing care to people with, and at risk for, HIV disease and/or viral hepatitis. PRN is committed to improving the diagnosis, management and prevention of these epidemic viral diseases and their complications, and to enhancing the broad spectrum of skills utilized by our members.
PLEASE NOTE: ALL MEMBER INFORMATION IS KEPT CONFIDENTIAL.
Please fully complete application:
|
| * Email Address
Your username will be the same as your email address
|
|
| * Password |
|
| * Password Confirm |
|
|
* First Name
|
|
|
* Last Name
|
|
|
* Mailing Address
|
|
|
Additional Address Line
|
|
|
* City
|
|
|
* State
|
|
|
* ZIP Code
|
|
|
Phone (Mobile/Text)
|
|
|
* What is your profession/training?
(membership is limited to these degrees)
|
|
|
* Other Profession
|
|
|
* Medical License #
|
|
|
* State of Licensure
|
|
|
* Board Certified?
|
|
|
What is your main specialty?
|
|
|
Other Specialty
|
|
|
* Are you credentialed in HIV medicine by AAHIVM?
|
|
|
* Are you a member of HIVMA or IDSA?
|
|
|
* In what type of setting do you mainly practice?
|
|
|
Other Type of Practice
|
|
|
How many years have you been in practice?
|
|
|
* Location of Primary Medical Practice by ZIP Code
|
|
|
Employer
(name of individual, hospital, university or organization employed by, if applicable)
|
|
|
Does your practice include:
(Please check all that apply)
|
|
|
In the last 12 months, how many patients with hepatitis C have you managed and treated, OR co-managed and treated with a subspecialist consultant?
|
|
|
Approximately how many HIV-positive patients do you care for in your practice?
|
|
|
Approximately how many HIV-negative patients on PrEP do you care for in your practice?
|
|
|
In your practice, which of the following at-risk populations do you serve?
(Please check all that apply)
|
|
|
What other at-risk populations do you serve?
|
|
|
|
|
* Submit the word you see below:
My answers to the above questions are true and accurate to the best of my knowledge.
* Indicates required fields
|
