NHCMA SPEAKERS RESOURCE 
INFORMATION SHEET

 

Please complete and submit the form below.

 
Physician Name:
Office Street Address:
City, State, Zip
Office Phone:
FAX:
E-mail:
Specialty (1):
Specialty (2):

The topics I am best able to address are (please check the topic(s) and specify):

Clinical Research

 

Socio-economic Issues
General Health Topics

 

 Physician/PatientRelationship
Prescription Drugs

 

 Malpractice/Tort Reform
Managed Care/Third Party Payors

 

 Medicare
Medicaid
 Other

 

Please indicate which platform(s) you would be most comfortable in delivering medicine's message:

Comments to Newspaper Reporters Television Interviews Letters to Editors/Op-ed Articles
Public Speaking Engagements Radio Talk Show

 

If you have had prior public speaking experience, please indicate below (check all that apply):
Newspaper Television Radio
Legislative Testimony Community Organization

 

 

                                                     

 

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