Are you Board Certified?*
YesNoN/A

Board Certification Expiration Date *

Are you currently practicing in the field specified above?*

YesNo

Are you a faculty member at a university?*

YesNo

Has any board or committee ever taken action against you or to reprimand you, place you on probation, revoke, limit or otherwise affect your ability to practice?*

YesNo

Have you been denied membership or renewal thereof in any organization or institution?*

YesNo

Do you have malpractice insurance/Professional Liability that is currently in effect?*

YesNo

Have you ever had any criminal charges files against you?*

YesNo

Have you ever had a malpractice case decided against you?*

YesNo

Have you settled (or had settled by your insurance carrier) a malpractice case against you? *

YesNo

Have you ever reviewed a legal case as an expert for the defense or plaintiff? *

YesNo

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