FCS form

Contact information

* This field is mandatory

Country

*

Contact details

*

First name*

*

Last name*

Academic title

*

Work/Institution Email*

*

Phone*

Company details

*

Institution Name*

*

Fellowship Director Name*

*

Fellowship Director Email*

*

Department/Program*

*

Expected Graduation Date*

US Citizen - please note this is open to US Citizens Only

*

Yes

No

Check the cases you’re submitting

foundation-user.u54.checkcasessubmitted

Arterial

Venous

Both

Please select and acknowledge the following:

*

I have saved my documents under this format: My NPI Number – Arterial (or Venous/both)

*

I have removed all patient identifiers and Protected Health Information (PHI) under HIPAA

*

I have removed all of my personal information and only used my NPI number as an identifier

*

I give consent to Philips to contact me for other fellowship related events/activities

*

If selected as a winner, I agree that my eligibility to perform services on behalf of Philips will be subjected to my execution of Philips’ standard health care provider consulting contract

How did you hear about us?

foundation-user.u54.howdidyouhear

Search engine

Social media

Word of mouth

Philips Fellowship program

Conference

Other

Pleace specify

*

Philips Territory Manager*

What is cross border data transfer?

I agree on cross-border transfer of personal information.

I would like to receive marketing related electronic communications about Philips products, services, events and promotions that may be relevant to me based on my user preferences and behavior.