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Cardiologist Information

Title: *
Name of Cardiologist:
Email address of Cardiologist:
Phone Number of Cardiologist:

Hematologist/Oncologist Information

Name of Hematologist/Oncologist:
Email address of Hematologist/Oncologist:
Phone Number of Hematologist/Oncologist:

Other Information

Contact Name:
Phone of Key Administrative:
Contact Name:
Email of key Administrative:
Phone of Key Administrative:

Institution Information

Name of Institution:
city:
State/Province:
Country:
Country:
Zip/Post Code:
How would you describe your institution?:
Category:
Tag:

Other Information

Is your C-O program a dedicated C-O clinic?:
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How long has your cardio-oncology program been in operation?:
On average how many C-O patients do you see each month?:
Do you have any training program in C-O at your institution?:
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Have you become a member of IC-OS?:
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Did you take the IC-OS Certifying exam or did anyone at your practice?:
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What hematology/oncology or other subspecialties are regularly engaged with the C-O team (list the top 5)?:
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