QuestionPro Survey

Registrations are reviewed by the Masterclass Mentors. Priority will be given to surgeons who best fit the targeted learner criteria identified on the TFG Masterclass webpage. By submitting your application, you confirm your availability to attend the onsite components of the program in Salt Lake City, Utah, March 20th and 21st.

Personal Details:

Full Name

Address (street, city, state, postal code)

Country

Institution (if applicable)

Phone

Email Address

How many years have you been in practice post training?

Currently in medical school

Currently in training

0-5 years

6-10 years

11-20 years

21-30 years

Over 30 years

Where is your primary surgery location?

Surgeon-owned clinic

Corporate-owned clinic

Hospital-owned clinic

Private hospital

Public hospital

Academic institution or non-profit

Retired or do not currently perform surgery

Other (Please specify.)

What is your average ANNUAL volume of retina patients?

Don’t see retina patients

Less than 50

51 to 100

101 to 200

201 to 300

301 to 500

500 or more

Approximately, how many patients do you see PER MONTH that you would consider as having dry AMD or geographic atrophy?

I don’t see retina patients

Less than 5 patients

6-10 patients

11-30 patients

31-50 patients

51-100 patients

More than 100 patients

How many complement therapy procedures have you performed in the past 12 month?

Less than 5

5 to 10

11 to 20

21 to 50

51 to 100

More than 100

None, I don’t use complement therapy

If none, how many complement therapy procedures were performed over the past 12 months in your practice/institution?

Briefly describe why you would like to be considered for this Masterclass program and your goal to achieve within this program (500 words or less)

I acknowledge that as part of the application process, I am committing to complete all online modules and attend the in-person case review, wet labs, workshops, and exam in Salt Lake City, Utah, on March 20th and 21st. TFG will cover the costs of hotel accommodations on March 20th and March 21st, breakfast, lunch, and dinner on March 20th, and breakfast and lunch on March 21st. All other travel costs will be the applicant's responsibility.

I acknowledge

Please add any questions, concerns, or requests you would like to accompany your application.

Are you willing to have your name and email address shared with independent education supporters of this program if you are accepted to participate?

Yes

Credentials: Please upload CV (optional)

If applicable, please enter your referral code:

For questions, please contact Dawn Alva at dawn@tfgeducation.com

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