Application Membership

Iranian Association for the Study of Pain (I.P.S)
Application Membership

First Name:

Last Name:

Phone:

Email:

Residential Address:

city:

Province:

country:

Postal Code:

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Place of Employment

city:

Hospital:

Clinic::

University:

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Academic /Professional Degree(s)

Academic /Professional Degree(s):

Year of Graduation:

Last Discipline:

Occupation:

Professional Title:

Specialty /Discipline

AnesthesiologyOncologyComplementary & Alternative MedicinesOrthopedics/RheumatologyDentistry/Oral MedicinePain MedicineFamily Medicine/Primary CarePalliative MedicineHealth Care/Research AdministrationPediatricsInternal MedicinePhysical Medicine and RehabilitationNeurologyPsychiatryNeuroscience/Pharmacology/PhysiologyPsychology/Social ScienceNeurosurgery/SurgeryPhysical TherapyNursingOther

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Do you have a background in pain research and analysis?

YesNo

Are you a member of the Local Association for the Study of Pain chapter in your country?

YesNo

Are you a member of the IASP chapter in your country?

YesNo

Would you be interested in establishing a collaboration with the Iranian Pain Society?

YesNo