RPS Express 90

RPS Express 90 Minutes Consultation Questionnaire

First Name *This question is required.

Last Name *This question is required.

Designation *This question is required.

Title *This question is required.

Email *This question is required.

Daytime Phone Number *This question is required.

Residency Program Name *This question is required.

Residency Program Location (city and state)  *This question is required.

Meeting date and time availability in the next 30 days *This question is required. Please List Times As: (8 am-12 pm CT ); (12-5 pm CT); (Other - include time)

General topic(s) of consult *This question is required.

Comments

Please provide a specific issue you would like to discuss (if applicable)

Please provide additional details you'd like to share with your consultant prior to your consult (if applicable)

Who do you anticipate will be on the call from your program? Include titles. (To create an interactive experience in a virtual consult, we recommend limiting the number of participants to five individuals.) *This question is required.

I have the legal authority to bind the organization set forth in this order form to the Terms of Service for RPS Express Consults linked below and hereby agree to the Terms of Service *This question is required.

Agree

RPS Express Consult Terms of Service.