Stay Updated with Our Newsletter and Our CME Programs! Sign Up Now to Get Our Newsletter and More! DEF Newsletter Sign-up "*" indicates required fields Name* First Last Name Middle Suffix Email* Category (Select from drop-down)*Nurse PractitionerPhysician AssistantPhysicianResidentNurseMedical AssistantBiologic CoordinatorOffice ManagerIndustryStudentPharmacistDegree (Check all that apply)* DNP DO LPN MBA MD MPAS MPH MS MSN NP-C NP PA-C PA PhD RN Other / None How many years have you practiced in dermatology?* 0-5 years 6-10 years 11-15 years 16-20 years 21+ years Not In Practice Primary Practice, Company, or Institution Name* Preferred Mailing Address Line 1* Preferred Mailing Address Line 2 Address Type* Business Residence City* State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code* State of Residence*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificNPI Number* Mobile Phone NumberPlease indicate the average number of patients you see in a typical clinic day.*0-1011-2021-3031-4041-5051-6061-7071+Industry, does not applySelect any areas in which you have interest in participating.* Medical Dermatology Aesthetic Medicine/Cosmetic Dermatology Pediatric Dermatology Clinical Trials and Research Advisory Board Opportunities with Industry Industry, does not apply Thinking of educational opportunities, select all topics you are interested in learning more about.* Medical Dermatology Aesthetic Dermatology Pediatric Dermatology Practice Management Contracting/Negotiating Billing/Coding Meetings/Events in Dermatology Dermatology Industry News Emerging Therapeutics Skincare and Cosmeceuticals Energy-based Devices Diagnostic Tests Dermatopathology CME/CE Educational Opportunities Virtual Journal Clubs Industry, does not apply Please mark any associations to which you belong.* American Academy of Dermatology Dermatology Nurses' Association Society of Dermatology Physician Assistants State/Regional Dermatology NP Society State/Regional Dermatology PA Society Other / None How did you hear about DEF?*Colleague/FriendLocal/Regional PA or NP SocietyDEF WebsiteReachRxSocial MediaAttended a DEF EventOtherWhat are your favorite medical journals/periodicals? Add RemoveWhat is your favorite live medical education conference? Add RemoveWhat are your favorite medical/dermatology online resources? Add RemoveDo you agree to receive electronic communication from Dermatology Education Foundation (DEF) ?* Yes No No contact information will be shared with or sold to any third party. Information will be used in accordance with our Privacy Policy: dermnppa.org/privacy/PhoneThis field is for validation purposes and should be left unchanged.
