Residency Visit Request

Please enter your request in the form below. To move between entry boxes, use the tab key or your mouse. Pressing the enter key will submit the request.

 
Residency  
* Name of Program:
City:
* State:
Contact Information  
Name of Academic Chair:
Name of Residency Director:
Name of Residency Coordinator:
E-mail of Residency Coordinator:
Name of Research Director:
Name of ED Medical Director:
* Name of Contact Person for Visit:
* E-mail of Contact Person for Visit:
Telephone:
Fax:
Pager:
Number of Residents:
Number of Faculty (FTEs):

Preferred dates for visit (please list three dates and inclusive times, or day of the week of your typical conference and which months you have dates available)
 

Leaders: Please indicate the 5 leaders you most prefer. Assignments will be made based on leader availability for your dates with consideration of your request.

Click here for short speaker bios and topics

 

Are there specific non-clinical issues you would like the ACEP leader to address?
 

The speaker also will be pleased to give a clinical or practice management presentation.
Note that the topic will vary depending on which leader visits your program. Please refer to Speakers A to Z  or the Topic by Category to indicate your preference.

Thank you. We look forward to hearing from you.

 
      

Feedback
Click here to
send us feedback