The Hospitalist

SECTION 1

Please complete this section and proceed to either section 2, 3, or 4 below:

* Indicates required field

1. * Your Name:
2. * Mailing Address: Enter a mailing/postal address
3. * Your Telephone:
4. * Your Email:

SECTION 2

If you are a Hospitalist or Physician Member of SHM, please complete the following. Otherwise skip to Section 3:

1. Indicate your clinical focus: ---None Specified--- Adult Medicine Pediatric Medicine Adult and Pediatric Medicine Not Applicable
2. Indicate your employer model: ---None Specified--- Academic (university or medical school) ER or critical care Hospital or health system Local hospitalist only group Multi-specialty group Multi-state hospitalist-only group Other
3. Other, please indicate:
4. Year you became a hospitalist:
5. Are you a member of SHM? : Yes No

Education

1. Professional School:
2. Year Graduated:
3. Specialty:
   Internal medicine
   Pediatrics
   Family practice
   Med/Peds
   ER
   OB/GYN
   Surgery
   Psychiatry
4. Sub-specialty (check all that apply):
   Allergy
   Cardiology
   Critical care
   Endocrinology
   Gastroenterology
   Hematology
   Hypertension
   Infectious Disease
   Metabolism
   Nephrology
   Oncology
   Palliative Care
   Pulmonary
   Rheumatology
   

SECTION 3

If you are a Resident, Fellow, Medical Student, Nurse Practitioner, Physician Assistant, or PharmD, please complete the following. Otherwise skip to Section 4

Residents/Fellows/Nurse Practitioners/Physician Assistants

1. Indicate specialty/subspecialty:

Medical Students

1. Indicate current year of study:
2. Indicate the total length of the program:

PharmD

1. Indicate employer model:

SECTION 4

If you do not fall into any of the categories above, you can still subscribe to The Hospitalist for a fee:

1. Are you eligible for free subscriptions: Yes No

Paid Subscription Rates

1. Institutions: $150
2. Individuals: $75
3. Affiliate (e.g. administrator, CPA, public policy): $35

SECTION 5

1. Security Digits:
2. Enter numbers displayed above: