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TEACH Observation/Consultation Request Form
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Contact Information
First Name
Last Name
Phone
Email Address
Department:
Role:
Are you a TEACH Member?
Yes
No
Service requested:
Observation
Consultation
Requested Observer:
Select from the list below:
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No Preference
Jennifer Cleveland, PharmD
Chad DeMott, MD
Mahtab (Mattie) Foroozesh, MD
Bruce Johnson, MD
Anita Kablinger, MD
Daniel Lollar, MD
Shari Whicker, EdD, MEd
Sarah Harendt, PhD, MS
Charles Paget, MD
Arthur Ollendorff, MD
Christi Stewart, MD
Paul Dallas, MD
Teaching activity you would like observed
Is this activity online or in-person?
Online (synchronous)
In-person
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