Add me to the supporters list!

Thank you for visiting this page, it means you are considering openly supporting my candidacy publicly.  For some, such a public endorsement is a substantial commitment and I want to thank you in advance for going the extra yard.  This form will feed our supporters web page after we vet the entries for accuracy.

In the form below simply add your name and title/position/practice (private practitioner/Department Head/Chairperson/Attending/Resident)

Your Name (required)

Your Title (required)

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