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First Name:		Middle Name:
Last Name:		Email: .gov or .mil only
Specialty/Duty Title:		Department:	*** Select a Department *** ----- Other ----- Adolescent Medicine Allergy Immunology Anesthesiology Audiology and Speech Behavioral Health (Multidisciplinary) Burn Trauma COE Cardiology Cardiothoracic Surgery Case Management Chaplain Child and Adolescent Psychiatry Colon/Rectal Surgery Community Health Nursing Concussion Clinic COVID-19 Vaccine Medical Contraindications Consult Critical Care Dentistry Dermatology Dive Medicine DWMMC Emergency Medicine Endocrinology ENT Family Medicine Fleet Liaison/Military Liaison Flight/Brigade Medicine Gastroenterology General Medicine General Surgery Genetics Hematology Oncology Hospital Corpsman/Medic Infectious Disease Information Management Internal Medicine Joint Patient Liaison Office Laboratory Medical Ethics Neonatology Nephrology Neurology Neuropsychology Neurosurgery Nursing Nutrition OB/GYN Occupational Medicine Occupational Therapy Ophthalmology Optometry Oral/Maxillofacial Surgery Orthopedics Pain Management Pathology Patient Administration Patient Movement Patient Safety Pediatric Cardiology Pediatric Child Abuse Pediatric Critical Care Pediatric Dentistry Pediatric Developmental Pediatric Endocrinology Pediatric ENT Pediatric Gastroenterology Pediatric General Pediatric Hematology Oncology Pediatric Infectious Disease Pediatric Nephrology Pediatric Neurology Pediatric Neurosurgery Pediatric Psychology Pediatric Pulmonary Pediatric Rheumatology Pediatric Surgery Pediatric Urology Pharmacy Physical Medicine and Rehabilitation Physical Therapy Plastic/Reconstructive Surgery Podiatry Preventive Medicine Psychiatry Psychology Pulmonary Radiation Oncology Radiology Referrals Office Resident Rheumatology Sleep Medicine Social Work Sports Medicine Surgery Telehealth Toxicology Trauma Surgery Undersea Medicine Urology Vaccine Healthcare Vascular Surgery Veterinary
Organization: *on ship users select "fleet"		Ship/Squadron/Unit:
Military Branch:	Select Service Branch AIR FORCE ARMY COAST GUARD MARINES NAVY SPACE FORCE OTHER VA STATE DEPARTMENT
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