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New House Staff Information Form

First Name:
Middle Name:
Last Name:
Maiden Name:
Name you go by:
Department:
Specialty:
Level:
Home Phone:
Current Street Address:
Current City/State/Zip:
Email Address:
Permanent Street Address:
Permanent City/State/Zip:
Social Security Number:
Date of Birth:
Marital Status:
Spouse Name:
Race:



Gender:

Place of Birth:
Citizenship:
Visa Status (if non-USA):
If you are a Foreign National you may be eligible to be exempted for FICA (Social Security-Retirement).
Medical School Graduated From:
Date of Graduation:
AOA: If yes, year of induction:
Person to Notify in Case of Emergency:
Name:
Address:
Phone Number

If you have had any prior training, ie, internship, residency or fellowship, please list below:

Dates: Institution: Type:


Please provide this additional information to allow us to set you up to obtain the appropriate scrubs.
Scrub Size (top)
(pants)

Will you be in the OR?

If so, how many days out of the week are anticipated in the OR?


  
 

Copyright: Wake Forest University School of Medicine and North Carolina Baptist Hospitals. All rights reserved.

Medical Center Boulevard

Winston-Salem, NC 27157

The information on this Website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified healthcare provider. If you have a medical problem or a health-related question, consult your physician or call Health On-Call at 336-716-2255 or 1-800-446-2255.

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Last Modified: 6/5/2007