First Name

Last Name

Email

Street Address

Address Line 2

Country

Phone

Your professional license (past or current)

Years of Service at Hennepin Healthcare

What year did you depart from Hennepin Healthcare?

Practice Areas – Check all that apply

Administrative

Burn

ICU

Pediatrics

OB/GYN

OR

Med/Surg

Cardiac

Education/Training

Trauma Services

Emergency Department/Urgent Care

Outpatient Care

Clinics

Infection Control

Employee Wellness

Transplant

Informatics

Community Clinics

Extended Care

Home Health/MVNA

Other (specify below)

If your area of practice is not listed, please list it here:

Are you a current HHS volunteer?

Yes

No

Please share special interest areas you would be willing to work on with others. 0/500 characters

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