User Registration Form

Enter in as much information as you can in the form. You will receive an email confirmation once it has been submitted.

Name*
First Middle Last
Salutation
Username*
Email*
Other Email
Street Address Line 1
Street Address Line 2
City
State
Zip Code
Country
Phone 1
Type of Phone Number 1
Phone 2
Type of Phone Number 2
Password*
Enter Password Confirm Password

Strength indicator
Database Fields
Account ID
Account Type
ABTS Certificate Number

Your Adult Cardiothoracic ABTS certification number
Year of ABTS Certification

Year of your Adult Cardiothoracic ABTS certification
Order of ABTS Certification (among women)

This is your number that reflects the number of women who obtained ABTS Certification since its inception
Membership Status
Degrees
- MD
- DO
- PhD
- MS
- MA
- PA
- NP
Institution or Practice Name
Practice Type
Facebook Link
Instagram Handle
Twitter Handle
Professional website
Specialty Area
Clinical/Research Interest

Areas of interest/focus, but not yet an expert in the area.
Clinical/Research Area of Expertise

Must have ~3 publications/talk on topic and consider yourself an expert in this area.
Residency
Residency Institution
Residency City
Residency State
Year Residency Completed
CT Fellowship (after General Surgery)
CT Fellowship Institution
CT Fellowship City
CT Fellowship State
Year CT Fellowship Completed
Training Paradigm
Advanced Fellowship 1
Advanced Fellowship 1 Institution
Advanced Fellowship 1 City
Advanced Fellowship 1 State
Year Advanced Fellowship 1 Completed
Advanced Fellowship 2
Advanced Fellowship 2 Institution
Advanced Fellowship 2 City
Advanced Fellowship 2 State
Year Advanced Fellowship 2 Completed
Academic Rank
Title 1
Title 2
Title 3
Organization 1
Organization 1, Position 1
Organization 1, Position 2
Organization 1, Committee 1
Organization 1, Committee 2
Organization 1, Committee 3
Organization 2
Organization 2, Position 1
Organization 2, Position 2
Organization 2, Committee 1
Organization 2, Committee 2
Organization 2, Committee 3
Organization 3
Organization 3, Position 1
Organization 3, Position 2
Organization 3, Committee 1
Organization 3, Committee 2
Organization 3, Committee 3
Journal 1 (if Editor or Editorial Board Position)
Title 1 (if Editor or Editorial Board Position)
Journal 2 (if Editor or Editorial Board Position)
Title 2 (if Editor or Editorial Board Position)
Publication 1
Publication 1 PMID
Publication 2
Publication 2 PMID
Publication 3
Publication 3 PMID
Publication 4
Publication 4 PMID
Publication 5
Publication 5 PMID
Photo
Max. file size: 512 MB.
Curriculum Vitae (CV)
Accepted file types: doc, docx, pdf, txt, Max. file size: 512 MB.
Email
This field is for validation purposes and should be left unchanged.

User Registration

User Registration Form

Database Fields