Wake Forest Baptist Medical Center
Surgical Critical Care and Acute Care Surgery
Application for Fellowship


 

Last Name:

First Name:

Middle Name:

Preferred Name:

Email Address:

Street Address:

City:

State:

Zip:

Contat Phone:

    

Visa Status (if applicable):

 

 

TYPE OF FELLOWSHIP FOR WHICH YOU ARE APPLYING


MEDICAL EDUCATION:

 

Internship

Residency

Additional

Residency Program:

Location:

Specialty:

Dates:

 



LICENSE INFORMATION: 
Current State Medical License:

State

License No.

Expiration

      

 

Has your state license or application for state license ever been denied, suspended or revoked?
 

Has your membership on a hospital's medical staff ever been denied, suspended or revoked?

 

Have you ever had your state or federal controlled substance license (DEA) denied, suspended or revoked?

 

Have you ever been convicted of a felony?

 

Have you ever been found guilty of malpractice or negligence?  
If yes to any please explain:   

 

LETTERS OF RECOMMENDATION:

List persons from whom you are requesting letters of recommendation (minimum of three). 
Include the Program Director of your most recent training program, and have the letters sent directly to:
  
R. Shayn Martin, MD FACS
Director, Surgical Critical Care Fellowship
Wake Forest Baptist Medical Center
Department of General Surgery
Medical Center Boulevard
Winston-Salem, North Carolina 27157

REFERENCES:  

Name

Position

Facility

 

 

 

 

 

How did you learn about our program? (optional)

If internet list website here:

If other list here: 

 

 

  
 By selecting "I agree" I am signing this form.  (This item is in lieu of a signature when applying online.)

 

 

Quick Reference

Surgical Critical Care Fellowship
Ways to Give
USNWR 2013-2014Magnet Hospital RecognitionConsumer Choice2014 Best DoctorsJoint 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.