Physician Case Request Form

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Please fill out this form so that you can begin being assigned cases from Physicians for Human Rights.

Name *

Email *

Specialty *

Gender *

Female

Male

Prefer not to say

其他:

If requested, would you be available to give oral testimony (can be done by phone or in person) when the case is heard? *

Yes

In order to take a case with PHR, you must have completed their training and registered with them. Have you registered with PHR? (You can register with them using this link: https://www.tfaforms.com/4641939)

Yes

其他:

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If you are a resident, do you have an attending who can act as a preceptor to your cases? Please list their name below.

When would you like the evaluation to take place *

Do you have an office or exam room available for you to use to conduct case evaluations? (Otherwise cases can be conducted on Wednesday evenings in coordination with the BFC) *

Yes

Any other comment/question?

Thank you!

A Case Manager will request a case from PHR and contact you to help coordinate selecting a case and conducting the evaluation. Please be on the lookout for follow up emails!

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