Faculty Invitation

Precision PCI
October 7-8, 2022
In Person Symposium

Name(Required)
Enter your full name exactly as it should appear in the meeting materials.
First Last

Degrees/Credentials(Required)
Enter the degrees/credentials you would like to be included in the meeting materials.

Salutation(Required)

Please indicate if you will be able to participate as an in person faculty member in Santa Monica, California(Required)

Hospital/Affiliation(Required)

Title(s)(Required)

Mailing Address(Required)
Street Address City State / Province / Region ZIP / Postal Code Country

Email(Required)
Enter Email Confirm Email

Assistant's Email Address
If you would like us to include your assistant on meeting correspondence, please add their email here.

Phone Number(Required)

Phone Type(Required)

Fax Number

Photograph
The forthcoming Precision PCI website will include a faculty section with speaker photographs, names, and affiliations. Please indicate if you give your approval to include your photograph on the website for this purpose only.

Yes, I give permission to use my photograph on the Precision PCI website

No, I do not give permission to use my photograph on the Precision PCI website

Please upload a photograph for the website
Photos should be at least 400x400px and include some open space around the head area. Please use this image of Dr. Samuels as a guide for how they will be cropped. If you gave your permission to include your photograph on the website but do not upload a photo, we will use the most recent photo we have on file.
Accepted file types: jpg, jpeg, png, Max. file size: 200 MB.

Comments
If you have any comments or questions, please let us know in the space provided below.

Faculty Invitation

Precision PCI October 7-8, 2022 In Person Symposium

Precision PCI
October 7-8, 2022
In Person Symposium