1.
 
COVID–19 is putting a tremendous strain on physicians, especially those on the front lines, and California is in the middle of experiencing an unprecedented surge in patient care needs. In collaboration with the Governor’s office and our regional government agencies, San Diego County Medical Society (SDCMS) is calling on physicians to volunteer their time and talent in service to impacted communities locally.
 
If you are willing and able to volunteer your services, please complete and submit the registration form below.
 
Should the need arise, we’ll contact you with opportunities to help.
2.
* Required Fields
[For internal use only to assist with deployment efforts]
First Name *

3.
Last Name *

4.
Email Address *

5.
Mobile Phone *

5.1.
HOME ADDRESS
Street *

5.2.
Apartment / Unit / Other

5.3.
City *

5.4.
State *

5.5.
Zip Code *

6.
Age

7.
MBC License Number *
[MEDICAL STUDENTS ENTER N/A]

8.
Primary Specialty *

9.
Hospital Affiliations / Privileges

10.
Distance Restrictions?
No
Yes
10.1.
11.
Time Restrictions?
No
Yes
11.1.
12.
Comments / Questions

13.
Thank you for your consideration and service!
13.1.