Call for Poster Abstracts - Mid-Atlantic Society for Post-Acute and Long-Term Care Medicine

Complete the Form Below to Submit Your Poster Presentation Proposal

Poster Title *

Presenter Name *

First

Last

Credentials *

Education / Degrees / Certifications

Organization

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

E-mail where you can be reached regarding membership (this address will not be shared without your permission.)

Phone

Fax

Indicate if in training *

Who is the primary presenter? *

Site of Service

Please indicate which site of service along the Post-Acute and Long-Term Care Continuum that your presentation will address

Abstract *

300 Word Limit

Presentation at professional conferences related to topic to be presented

Publications related to topic to be presented

Disclosure Acceptance *

Signature