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New House Staff Information Form

First Name:  
Middle Name:  
Last Name:  
Maiden Name:  
Name You Go By:  
Home Phone:  
Current Street Address:  
Current City/State/Zip:  
E-mail Address:  
Permanent Street Address:  
Permanent City/State/Zip:  
Date of Birth:  
Marital Status:
Spouse Name:  
Place of Birth:  
Visa Status (if non-USA):  

If you are a Foreign National you may be eligible to be exempted for FICA (Social Security-Retirement).

If you are eligible and do not wish FICA withheld, please check . Please present J-Visa for exemption from FICA.

Medical School Graduated From:

Date of Graduation:  
If yes, year of induction:


Person to Notify in Case of Emergency:
Phone Number  

It is extremely important that a detailed chronological history is provided. 

This denotes all history post medical school graduation,  i.e.   internship,

residency, fellowship, translational year program, vacation, sabbaticals, etc.  

Dates:                                         Institution      
 Training or Activity:  

Please provide this additional information to allow us to set you up to obtain the appropriate scrubs.
Scrub Size (top)  

Will you be in the OR?
If so, how many days out of the week are anticipated in the OR?

Quick Reference

Graduate Medical Education

Phone 336-716-5222
Fax 336-716-6415


8 am to 4 pm

Mailing Address

Graduate Medical Education Office
Wake Forest Baptist Medical Center
Medical Center Boulevard
Winston-Salem, NC 27157

Ways to Give
Six Wake Forest Baptist Specialties Earn U.S. News RankingsComprehensive Cancer Centers National Designation is Renewed2017-2018 Best DoctorsNursing Magnet StatusJoint Commission Report

Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.

© Wake Forest Baptist Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157. All Rights Reserved.