Medical Specialist CerviQ App Application Form

IN OUR GOAL TO UNDERSTAND YOUR PREFERENCES, KINDLY ANSWER THE FOLLOWING QUESTIONS BELOW:

Would you be willing to partake in our teleconsultation program?Select OneYesNo

Would you be willing to participate in research on Digital Cervicography?Select OneYesNo

Do you accept cervical reads with pay from other sources outside of your own?Select OneYesNo

Do you accept cervical reads from charitable organizations?Select OneYesNo

Would you wish to be informed on upcoming training seminars on VIA and Digital Cervicography?Select OneYesNo

Would you feel comfortable to train other OB-Gyne in doing cervical reads?Select OneYesNo

Please attach an image of your latest PRC ID

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