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Surgeon Submission
Profile information
Full name
*
Please write your full professional name as you'd like it to appear, including your relevant abbreviated medical credentials (ex: MD, FACS).
Surgeon type
*
Healthcare facility or affiliation
Include the name of your practice, hospital or clinic.
Website link
Include a URL link to the website for your practice, hospital or clinic.
Address
*
Address
City
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District of Columbia
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Maryland
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Northern Mariana Islands
Ohio
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South Carolina
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Tennessee
Texas
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U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
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Armed Forces Pacific
State
Profile photo
(Optional) Image should be a minimum of 500px by 500px Accepted files formats are .jpg, .gif, .png
Accepted file types: jpg, gif, png, Max. file size: 5 MB.
About me
Share any relevant information about yourself, your education, experience, practice, etc. that would be helpful for patients to know.
Why I use Zip
Let patients know why you use Zip, explain your experience using it, and / or share what benefits Zip offers patients.
Contact information
Contact name (if other than yourself)
Email address
*
This is my preferred contact method
Phone number
*
This is my preferred contact method
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I agree to the
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