New House Staff Information Form

First Name:  
Middle Name:  
Last Name:  
Maiden Name:  
Name You Go By:  
Department:  
Specialty:  
Level:
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:  
Race:
Other:  
Gender:
Place of Birth:  
Citizenship:  
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:  
AOA:
If yes, year of induction:

 

Person to Notify in Case of Emergency:
Name:  
Address:  
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)  
(pants)  

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

Quick Reference

Residencies

Phone 336-716-3465
Fax 336-716-6415

E-mail
hostaff@wakehealth.edu

Ground Floor, Meads Hall
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.