Apply to become a member

When you become a WSRM member, you become a member of the largest online community of reconstructive microsurgeons in the world. Gain access to valuable information within the reconstructive community including our online forum, online news and journals, important dates for meetings and events held around the world, and a database of 350 other surgeons.

Please check which category you are applying for:*
- Candidate*
- Active (Clinician)
- Active (Researchers)
* Candidate applicants please complete only those items applicable
Personal Data

(Please TYPE name exactly as you wish it to appear on your certificate, including designations)
Name*
Office Address*
Office Phone*
Office Fax
Email*
Home Address*
Home Phone*
Home Fax
Date of Birth*
Place of Birth*
Citizenship*
Name of Wife/Husband
Present Position*
Institution*
Professional Qualifications
University*
Degree*
Date*
Medical School*
Degree*
Date*
Graduate School*
Degree*
Date*
Residency*
Degree*
Date*
Microsurgery Fellowship
Other Post-Residency Training
Licensed to Practice Medicine In:*
Specialty Boards Complete
Membership in Professional Organizations
Hospital and University Staff Affiliations
From/To*
Hospital or University & Dept.*
Name of Chief*
Your Position*
From/To
Hospital or University & Dept.
Name of Chief
Your Position
From/To
Hospital or University & Dept.
Name of Chief
Your Position
From/To
Hospital or University & Dept.
Name of Chief
Your Position
From/To
Hospital or University & Dept.
Name of Chief
Your Position
Present Professional Activities

For Clinicians
How long have you been in practice (after fellowship)?
In present location?
Number of operations performed last year?
How many of these were Microsurgerical cases?
Present Professional Activities

For Basic Scientists
Please list all research activities, relevant publications to microvascular surgery and sources of funding.
Sponsor

A sponsor is required for all new membership applications. The sponsor must be an active member of the World Society for Reconstructive Microsurgery. The sponsor must write a letter, addressed to the Secretary General, supporting your application.
Sponsor Name*
Sponsor Address*
Sponsor Email*
Other letters of recommendation from those familiar with your professional activities are welcomed. The committee is particularly interested in receiving letters from chiefs of service of the hospitals, clinics, and universities where you trained and work.

Forward the completed application and requisite enclosures to: World Society for Reconstructive Microsurgery Office, 500 Cummings Center, Suite 4400, Beverly, MA USA. You can send via fax (+1-978-524-0498) or send us an email

Apply to become a member

Personal Data

Professional Qualifications

Hospital and University Staff Affiliations

Present Professional Activities

For Clinicians

Present Professional Activities

For Basic Scientists

Sponsor