Doctor Intake Survey
Please complete this form if you are a doctor in the Corus network.
Once your intake survey is received, we will use this information to draft your biography, update the practice website, and distribute communications.
Important: Remember to hit submit at the end of the survey!
Contact Information
Your Name (First + Last)
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Your Email Address
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Practice Name
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Biography Information
Please select how you would to be referred to in your biography:
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Dr. First Name
Dr. Last Name
Other
If Other, please indicate here:
Where are you from (city, state/province)?
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Do you speak any languages other than English that you would like mentioned?
Voice you'd like your bio written? (professional, friendly, etc)
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Please outline any awards or accolades you would like us to include:
Education
Where did you complete your undergraduate degree?
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What year did you complete your undergraduate degree?
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Please enter your undergraduate degree and field:
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Where did you complete dental school?
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What year did you complete dental school?
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Please select your dental school degree:
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DDS
DMD
Where did you complete orthodontic school?
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What year did you graduate orthodontic school?
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Please enter your orthodontic degree:
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More About You
What makes you passionate about your career?
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Please outline any industry groups you are part of (current or prior) and in what capacity (IE Board Member of AAO):
Are there any causes or charities that you are involved with or areas of interest you might consider in the future?
What do you like to do in your free time? Hobbies, personal interests, favourite team, etc?
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Is there anything else you'd like to add that hasn't already been mentioned?
Existing Bio for Edits (Optional)
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Upload Headshot
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