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Family Physician of the Year
Nomination Form
Nominator Information:
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
Zip Code:
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Email address:
*
Cell Phone Number:
*
Nominee Information:
First Name:
*
Last Name:
*
Designation:
*
Address:
*
City
*
State
*
Zip Code
*
Email address
*
Home Phone Number:
*
Office Phone Number:
*
Cell Phone Number
*
Is a member of the LAFP ?
*
Yes
No
AAFP ID:
*
Date of Birth:
*
Practice Name:
*
Address
*
City:
*
State:
*
Zip Code:
*
Medical School Completed/Year:
*
Residency Program Completed/Year:
*
Total years in practice:
*
Board Certified:
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Yes
No
Practice Type:
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Solo Practice
Group Practice
Multi-specialty group
Academic
Retired
Other
Please describe how the family physician exhibits the following criteria:
How does this family physician provide their patients with compassionate, comprehensive, and caring family medicine on a continuing basis?
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How is this family physician directly and effectively involved in community affairs and activities that enhance the quality of his/her community?
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How does this family physician act as a role model professionally and personally to their community, other health professionals, and/or residents and medical students?
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How does this physician stand out among their colleagues?
*
Please upload the following documents before submitting this form:
A high resolution professional head shot
*
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A short bio of the nominee
*
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Current curriculum vitae (limited to three pages)
*
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Supporting Documentation: (Maximum of eight pages of supporting documentation)
×
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