Agreement to Participate

Please place a check mark in the boxes below, as appropriate,
to indicate your agreement and understanding of each.

Please note that all fields are mandatory.

I have read and understand the confidentiality and
personal information section on this form.


I understand that I can opt out of this program at any time by notifying
the program administrator by email


I agree to participate in this program

Personal Information
Name:
E-mail Address:

Demographic Information

The following demographic information is collected in order to appropriately
target questionnaires to appropriate participants.
Language of correspondence: English    French
Province of Residence:
Does your practice specialize in a particular area? Yes    No
If yes, please indicate your specialization:
Where do you regularly practice anesthesia?