Outpatient Surgery Free Subscription

	*Outpatient Surgery* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Outpatient Surgery*, please answer ALL of the questions on the form below.
	The magazine publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA

1.	*Do you wish to receive a FREE subscription to Outpatient Surgery?*

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First Name:
Last Name:
Degree:
	(MD, RSN)
Job Title:
	(Ex: Director, Vice President, Project Manager, etc.)
Facility Name:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Mailing Address:
Department/Division:
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Email Address:
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Number of Steril ORs:
Number of Endoscopy Rooms:

Which of the following best describes your industry? (select only one)

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What is the approximate number of employees in your company? (select only one)

Yes, please auto-fill my contact information for other publication qualification forms.

2.	Month of Birth:

3.	Which best describes your professional title? (select only one)

Administrator / Director / Manager Director, Surgical Services / Director of Nursing

Medical Director / Chief Surgeon Anesthesiologist / Nurse Anesthetist

OR Manager / Supervisor Other

4.	Which best describes the type of facility you are associated with? (select only one)

Acute-care Hospital Ambulatory Anesthesia

Licensed or Certified ASC Other

Office with Surgery Suite

5.	I have influence over the purchase of: (select all that apply)

None Business Supplies & Services

Capital Equipment Surgical Supplies

Implants Surgical Pharmaceuticals

6.	The facility I am associated with is located in: (select only one)

United States Canada Other

7.	We serve the following specialty areas: (select all that apply)

All ENT

Dermatology General Surgery

Gastroenterology Ophthalmology

Gynecology Pain Management

Orthopedics Podiatry

Plastic Urology

Dental / Oral Surgery

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