Physician Information Form - for active staff only

For information about getting your photograph taken you can make an appointment with Benjemax Studio, 928 634-4175. There is no charge for the sitting.

PHYSICIAN NAME:

ADDRESS OF PRACTICE:

CITY: STATE: ZIP:

PHONE: TOLL FREE: FAX:

SPECIALTY:

MEDICAL SCHOOL: CITY/STATE:

DATE COMPLETED MEDICAL SCHOOL:

INTERNSHIP: CITY/STATE:

RESIDENCY: CITY/STATE:

BOARD CERTIFICATION:

YEAR JOINED VVMC MEDICAL STAFF:

SPECIAL PROCEDURES/MEDICAL INTERESTS:

PROFESSIONAL ORGANIZATIONS:

I AUTHORIZE NAH MARKETING DEPARTMENT TO INCLUDE MY PHOTO AND INFORMATION ABOVE IN: NEXT VVMC PHYSICIANS' REFERRAL DIRECTORY  YES  NO
NAH WEB SITE ONLINE DIRECTORY YES  NO

Please check spelling before pressing submit. The information above will be placed in the appropriate places as it was received. Thank you.

If you have questions or problems with this form please email us or call 928 639-6551.

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Northern Arizona Healthcare - 1200 N. Beaver St., Flagstaff, Ariz. 86001 - 928 779-3366
Flagstaff Medical Center - 1200 N. Beaver St., Flagstaff, Ariz. 86001 - 928 779-3366
Verde Valley Medical Center - 269 S. Candy Lane, Cottonwood, Ariz. 86326 - 928 639-6000
VVMC - Sedona Campus - 3700 W. Highway 89A, Sedona, Ariz., 86336 - 928 204-3000