Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name *FirstLastFacebook Profile Name *Are you already a member of our Women Physicians Weigh In facebook group? *YesNoNOTE: if you are already a member of our Facebook group, you likely will NOT receive an email. YOU WILL have automatic access to the website. Facebook User URLNot required, but helpful: Most easily found if logged into FB via a desktop: click on your personal timeline, then copy and paste the web address that is on top of the screen. If on a mobile device it is found in the setting, info area. Email *File Upload *Please upload picture verification. This need to be a pic that cannot just be found online. Examples are work/badge ID with photo and name or driver's license. Feel free to cover all info except photo and name on the driver's license. NextWhat is your specialty? *Allergy/asthma/immunologyAnesthesiologyCardiologyDermatologyENTEndocrinologistEmergency MedicineFamily MedicineGastroenterologyGeneral SurgeryGeriatric MedicineHeme/oncInfectious DiseaseInternal MedicineInternal Medicine/PedsNeonatologyNephrologyOb/GynOpthomologyOrthopedicsPathologyPediatricsPMNRPulm/Crit CarePsychiatryRadiologyRheumotologyOther SurgeryUrologyOther, see belowOther Specialty?List one state in which you have or had (if retired) a medical license? *Submit