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ABOUT THE GALEN EXAM

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GALEN Exam Registration

Please complete the Registration Form below, then click the SUBMIT button to submit the form. After submitting the form, you will be directed to the payment page to complete your registration for the GALEN Exam.
Bold Fields Required.

First Name
Middle Initial
Last Name
Email
Degree(s)
Specialty
Affiliation
Business Name
Business Address 1
Business Address 2
Business City
State/Province
Postal Code
Business Country
Business Phone
Business Fax
UPLOAD
Medical License

or fax to:
+1-202-315-3651

(file size maximum = 2.0mb, JPEG, or PDF accepted)
SPECIALTY
What is your medical specialty?
If Other:
PRACTICE
Where do you practice medicine?
Private Sector       Public Sector
If Both, indicate the % of each:   
% Private     % Public
What is your monthly patient caseload?
Patients
What is your annual patient caseload?
Patients
What percentage of your patients is living with HIV/AIDS?
Have you received training in HIV medicine?
How many years have you practiced HIV medicine?
Have you received training specific to the prescription of antiretroviral therapy?
How many years have you prescribed antiretroviral therapy?
What percentage of your patients is on antiretroviral therapy?
What percentage of your patients are women of child-bearing age (ages 15-44)?
What percentage of your patients are children or adolescents (ages 0-18)?
What percentage of your patients is coinfected with tuberculosis (TB)?
PAYMENT METHOD




 
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