Healthcare Advisory Board

$P\S\L Group Healthcare Advisory Board$

Share your opinions and medical expertise and make a difference today.

Sign up today to be part of our Healthcare Advisory Board (HAB). As a HAB member, you will:

•  contribute to improving medical products, services, and communications
•  earn rewards and honoraria for your valuable time and opinions
•  view results of studies taken by your peers

We respect the confidentiality and privacy of every Healthcare Advisory Board member. Your personal information will be treated with the utmost discretion. Please click here to view our privacy statement.

If you would like more information about the Healthcare Advisory Board, please click here.

Fields in bold are required

	First Name:

	Last Name:

	Email Address:

	Confirm Email Address:

	Country:

	Profession: Specialty: Subspecialty: Education / Training: Specialty: Setting: Specialty: (optional)

	Office Address Line 1: (primary work address)

	Office Address Line 2: (optional)

	City: State: State: Province: Province: Province: Department: County: State / Province / Region: (optional) State / Province / Region: ZIP Code: Postal Code: Zip / Postal Code:

	Telephone Number:

	Fax Number: (optional)

Membership in HAB is limited to bona fide healthcare professionals. In order to verify your eligibility, you must select one (1) of the options below. Note: You will not receive any invitations to participate in market research studies until you have been verified as a bona fide healthcare professional.

Provide your Medical School Graduation details
Note: Medical school verification is not available for every country. In the event that we are unable to verify your medical school, we may ask you to fax us a copy of your medical license.


	Medical School Country: (where you attended) Medical School State: (where you attended) Medical School Province: (where you attended) Medical School: (from which you graduated) Medical School: (from which you graduated) Specify Other Medical School: Last Name: (at time of graduation) Year of Graduation:

Provide your Medical License details
Note: In the event that we are unable to verify your medical license, we may ask you to fax us a copy of your medical license.


	Medical License Country: (where you are licensed) Medical License State: (where you are licensed) Medical License Province: (where you are licensed) Medical License Number:

Fax a copy of your Medical License
Please fax a copy of your medical license to:

Fax Number: 001 303 291 3384
Attention: Laura Malett
Re: HAB Medical License Verification

Note: Please be sure to include your HAB Member ID, which you will receive upon completing this registration form (also contained in your confirmation email).

Fields in bold are required