Alabama Osteopathic Medical Association

* Full Name

* Practice Location (City and Zip Code)

* Specialty (Select One)

Allergy & Immunology
Anesthesiology
Cardiology
Dermatology
Emergency Medicine
Endocrinology
Family Medicine
Gastroenterology
Geriatric Medicine
Hematology/Oncology
Infectious Disease
Internal Medicine
Medical Genetics
Nephrology
Neurological Surgery
Neurology
Nuclear Medicine
Obstetrics & Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pathology
Pediatrics
Physical Medicine & Rehabilitation
Plastic Surgery
Preventative Medicine
Psychiatry
Pulmonology
Radiation Oncology
Radiology - Diagnostic
Rheumatology
Sleep Medicine
Surgery – General
Thoracic Surgery
Urology
Other

* I am willing to accept (for shadowing) Please select all that apply

Pre-medical students
1st Year Medical Students (OMS-I)
2nd Year Medical Students (OMS-II)
3rd Year Medical Students (OMS-III
4th Year Medical Students (OMS-IV)

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* I prefer to be contacted by:

Email
Telephone
Other

If other, please specify

* Practice/Company Name

* Contact Person (office manager etc.)

* Address

* City / Town

* State

* Zip Code

* Please check which months (tentatively) you are available for shadowing

* Please select what days of the week you prefer (tentatively) to be shadowed

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