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Liaison Interest Form

Liaison Program Interest Form

Thank you for your interest in the Academy Liaison Program! Please answer the following questions and we will reach out to you when new liaison opportunities arise. 
5. What is your primary practice area(s)? *This question is required.
6. What are your primary procedures and services? *This question is required.
7. What is your primary practice setting? *This question is required.
8. Do you serve a patient population that: *This question is required.
9. Do you serve a rural patient population? *This question is required.
10. Do you treat Long-COVID patients? *This question is required.
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