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Fill The Form Below
Name
Title
Professor
Dr.
Student
E-mail Address
Specialty
Pediatric surgery
General surgery
Urology
Gynecology
Orthopedic surgery
Neurosurgery
Plastic surgery
ENT surgery
Junior doctor
Medical Student
Other
I am applying to be
Mentor
Mentee
Both
Please insert your photo
Upload
Please insert your photo
Upload
Mailing address
City
Division/State/Province
Postal/Zip code
Country
Phone number (please include country code)
Time zone
Do you use WhatsApp?
Yes
No
Do you want to be added to HelloSurg Network WhatsApp group?
Yes
No
Maybe
How would you like us to communicate with you?
Email
Phone
WhatsApp
Native language
Affiliated hospital/medical college
Affiliated hospital/medical college street address
Affiliated hospital/medical college - City
Affiliated hospital/medical college - Division/State/Province
Affiliated hospital/medical college - country
Affiliated hospital/medical college - phone number
Are you a licensed medical practitioner?
Yes
I am a student
Name of mentor(s)/mentees(s)
Mentor/mentee email(s)
Mentee written & spoken English comprehension
Beginner
Intermediate
Fluent
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