Pulmonary Hypertension Clinicians and Researchers (PHCR)

Secure Online Application Form

Already a member of PHCR? 1. Renew your membership 2. Nominate a colleague to join by sending the nominee's name, institution, and contact information to PHA's Medical Services Department at phcr@PHAssociation.org

Application Process:

Please fill out the form below to apply for PHCR membership. Your application will be reviewed by a member of PHA’s Scientific Leadership Council and you will be notified in a timely fashion of your membership status. If approved for membership, we will then ask you to pay the $135 annual membership fee. After the fee is received, you will be welcomed as a new member of PHCR.

QUESTIONS???
contact PHA's Medical Services Department at phcr@PHAssociation.org

Medical professional, but not a doctor or researcher?
Join PH Resource Network

Application Form Mailing / Contact Information: First Name:* Middle Initial: Last Name:* Suffixes:* Title:* Institutional Affiliation:* Address:*   Address 2: City:*   State / Province:*   Country: Zip / Postal Code:* Office Phone:* Fax: E-mail:* Website:* Primary Board Certification:* Secondary Cert:* Please be sure to list an office phone number and not a home or cell phone number, especially if you indicate you want your information posted in PHA's Find a Doctor listings. The PHCR trainee fee of $35 applies to applicants who are completing residency or fellowship programs and interested in pulmonary hypertension. The trainee fee gives access to all membership benefits except listing on the Find a Doctor section of the PHA website. After completion of training, membership will require renewal at the standard rate of $135 and can then be listed on the Find a Doctor section of the PHA website. Yes, I assert I qualify for the $35 trainee rate. Optional: These questions are intended to give the PHA and PHCR a better idea of how we might best represent and provide value to our membership. What are your objectives in joining PHCR (how can we best meet your needs)? Personal education about PH Advocacy on behalf of PH issues Participation in PHA Conferences Attendance in PHA Conferences Interaction with investigators in the field of PH research Interaction with clinicians involved with PH patients Participation in multicenter PH research projects Your PH Practice: one of the benefits of PHCR membership is being listed on the "Find a Doctor" section of the PHA website -- please indicate by checking the box if you do NOT wish for your contact and practice information to be listed Number of years involved in treating PH: Number of doctors in your practice who have specialized experience with PH patients: Number of nurse coordinators who have specialized experience with PH patients: Number of new PAH patients seen over past year with: Idiopathic pulmonary arterial hypertension Connective tissue disease Congenital heart disease Portopulmonary hypertension HIV   New PH patients seen over past year with: Parenchymal lung disease Chronic thromboembolic disease Number of treatment modalities initiated in patients within past year: Epoprostenol (Flolan) intravenously Iloprost (Ventavis) inhaled Thromboendarterectomy Treprostinil (Remodulin) subcutaneously Bosentan (Tracleer) orally Atrial septostomy Treprostinil (Remodulin) intravenously Sildenafil (Viagra) orally Lung/Heart Transplant Other: PH-related research or clinical studies with which you are currently involved: Your PHA role: "I am interested in… Any opportunities to participate in multicenter clinical studies. (Willing to be contacted directly by a study sponsor ) Any opportunity to participate in a multicenter registry. Actively participating (i.e., speaking) at educational conferences. Attending educational conferences. Participating in PHCR committees. xxxxx

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