Dr. 's Surgeon Profile Builder Form:

* What is the surgeon's FIRST NAME?

* What is the sugeon's LAST NAME?

* What PHONE NUMBER would you like listed for
patients to contact you? (Please include area code.)

* What is the STREET ADDRESS of your primary office?

If applicable, What is the OFFICE NUMBER
or SUITE of your primary office?

* What CITY is your primary office located in?

* What COUNTRY is your primary office located in?

* If your office is in the United States,
what STATE is your officelocated?

* What HOSPITAL(S) do you operate at?
(Please list the top three hospitals.)

* From which MEDICAL SCHOOL did you graduate?

* When did you graduate from Medical School?

Residencies and Certifications

Do you SPECIALIZE in a particular type of heart valve surgery?
If yes, what are your top three specialties?
(Example: Aortic Valve, MItral Valve Repair)

Do you have any RESEARCH INTERESTS?
If yes, what are your top three research interests?

* About HOW MANY cardiac procedures have you performed?

* About how many VALVE PROCEDURES have you performed?

Do you submit your surgical outcomes to the STS Database?

* What do you consider your GREATEST STRENGTH
as a cardiac surgeon? (Please describe.)

If available, please upload your picture:

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* Do you accept HEALTH INSURANCE?
If so, what are the top three insurance
companies you work with?

Do you have a YOUTUBE video?
If so, please include the link to embed the video.
This is found in the box on the youtube
video page titled "Embed".

Please upload an image for the Youtube video:

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Do you have a website?

Please insert your web address
(example. www.yourdomain.com).

* What is the name of the primary cardiac center that you practice at?

* Please provide a general overview of the surgeon

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