DIGA 2021 - 2022 Affiliated DIG Contact Form
Hello! Thank you for your interest in being an affiliated DIG with DIGA! By filling out this form your school's DIG leadership will be provided with updates on opportunities in dermatology and be included in our DIG network for inter- and intra-regional events.

Our 2021 - 2022 Regional Directors are listed below. If you do not receive an introductory email from them within 2 weeks after filling this form, please follow-up with them.
Western: Martha Oberg - martha.oberg@wsu.edu 
Midwestern: Rebecca Goldberg - beckgold@med.umich.edu
Southern: Shifa Akhtar - sakht008@med.fiu.edu
Northeastern: Bansri Patel - bmp55@pitt.edu
Sign in to Google to save your progress. Learn more
Medical School *
City *
State *
Do you have a home dermatology program? *
Medical School Website (if available, provide your school's DIG webpage)
DIG Chapter Email (if applicable)
DIG Social Media Handles (twitter, IG, FB):
DIG Primary Contact Name (First & Last) *
DIG Primary Contact Title (President, DIGA Liaison, etc.) *
DIG Primary Contact Year *
DIG Primary Contact Email *
May the primary contact's email address and medical school be listed on our website? This will allow other school's DIGs or students near you without a DIG to contact you. *
DIG Secondary Contact Name (First & Last)
DIG Secondary Contact Title (President, DIGA Liaison, etc.)
DIG Secondary Contact Year
Clear selection
DIG Secondary Contact Email
DIG Advisor Name (First & Last)
DIG Advisor Title (Program Director, Associated Professor of Dermatology, etc)
DIG Advisor Email
Please only share if your DIG advisor would be comfortable in sharing their email - it will only be listed on our internal documentation.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms