NAME IN FULL: 

OFFICE ADDRESS (OR PREFERRED MAILING ADDRESS):

OFFICE TELEPHONE NUMBER:

E-MAIL ADDRESS:

UNIVERSITY DEGREE AND MEDICAL DEGREE:

UNIVERSITIES AND MEDICAL COLLEGES ATTENDED:

HOSPITALS WHERE YOU TRAINED:

HOSPITALS AT WHICH YOU PRESENTLY ADMIT PATIENTS:

NURSING HOMES USED NOW AND IN PAST (IF ANY)

(GIVE NAMES, ADDRESSES, DATES, APPROXIMATE NUMBER OF PATIENTS THAT YOU HAVE SEEN AT EACH INSTITUTION)

BOARDS TO WHICH YOU ARE ELIGIBLE:

BOARDS THAT HAVE CERTIFIED YOU:

STATES THAT HAVE LICENSED YOU:

APPROXIMATE NUMBER OF GERIATICS PATIENTS THAT YOU HAVE SEEN IN THE PAST:

APPROXIMATE NUMBER OF GERIATICS PATIENTS BEING SEEN AT THE PRESENT TIME:

WE ARE INTERESTED IN EMPHASIS ON HUMANITY, INTEGRITY, KINDNESS, AND RELIGIOUS VALUES IN MEDICINE:

WILL YOU FOLLOW THE LAWS OF THE TEN COMMANDMENTS AND OF THE GOLDEN RULE OR SIMILAR LAWS OF OTHER MAJOR WORLD RELIGIONS AND TRY AT ALL TIMES TO BE HUMANE AND KIND AND BRING RELIGIOUS LOVE OF HUMANITY TO ALL ASPECTS OF YOUR MEDICAL PRACTICE AND ENDEAVOR TO BE A TRULY HUMANITARIAN PHYSICIAN? YES___ NO ___

WILL YOU PROMISE TO ALWAYS TRY TO PROVIDE THE LATEST AND MOST THOROUGH AND EFFECTIVE TREATMENT OF ALL PATIENTS WITHOUT REGARD FOR THEIR ABILITY TO PAY, OR THEIR RACE, OR THEIR NATIONALITY, OR THEIR RELIGION, OR THEIR CREED AND BELIEFS, OR THEIR SEX, OR THEIR SEXUAL ORIENTATION, OR THEIR STATION IN LIFE, OR WHETHER THEY ARE RICH OR POOR, OR WHETHER THEY HAVE INSURANCE, AND NO MATTER WHAT THEIR NEED, WITHIN REASON, AND WHATEVER TYPE OF PATIENT OR TYPE OF ILLNESS, WHETHER A PATIENT IS A PRIVATE PATIENT OR HMO PATIENT OR PUBLIC AID PATIENT, OR ANY HUMAN BEING IN NEED OF MEDICAL TREATMENT? YES___ NO ___

DO YOU PROMISE TO BE ALWAYS HELPFUL, KIND, NEVER JUDGEMENTAL OR INSENSITIVE TO THOSE WHO ARE YOUR PATIENTS OR ANY PERSON WITH WHOM YOU MAY ENCOUNTER PROFESSIONALLY? YES ___ NO ___

PLEASE INDICATE EXACTLY HOW YOUR NAME SHOULD BE ENGRAVED UPON YOUR CERTIFICATE AS A DIPLOMATE OF THE AMERICAN BOARD OF GERIATRICS:


PLEASE INDICATE EXACTLY HOW YOUR NAME SHOULD BE ENGRAVED UPON YOUR CERTIFICATE AS A DISTINGUISHED FELLOW OF THE AMERICAN COLLEGE OF GERIATRICS SPECIALISTS:

SIGNATURE:______________________________________________________ DATE:_______________

For Diplomate Certification as a Diplomate of the American Board of Geriatrics and Associate Membership including appointment as Fellow of the American College of Geriatrics Specialists (F.A.C.G.S.), 
we must receive the following:

1-This application form, filled out clearly, signed, and dated.

2-Check or money order for $500 made out to: American Board of Geriatrics.

(No application will be viewed unless accompanied by the application fee.)

3-Essay on one of the geriatrics topics listed and approved by the Board.

4-All of the above mailed to: 
AMERICAN BOARD OF GERIATRICS
EXECUTIVE COUNCIL
2512 TELEGRAPH AVENUE
SUITE 201
BERKELEY, CA 94704

-OVERVIEW OF DRUG THERAPY IN MEDICAL ONCOLOGY IN GERIATRIC PATIENTS

-OVERVIEW OF TOXICITIES OF DRUG THERAPY IN MEDICAL ONCOLOGY IN GERIATRIC PATIENTS

-OVERVIEW OF DRUG THERAPY IN CLINICAL CARDIOLOGY IN GERIATRIC PATIENTS

-OVERVIEW OF TOXICITIES OF DRUG THERAPY IN CLINICAL CARDIOLOGY IN GERIATRIC PATIENTS

-OVERVIEW OF DRUG THERAPY IN ACUTE EXACERBATION OF CHRONIC RENAL FAILURE IN GERIATRIC PATIENTS

-OVERVIEW OF TOXICITIES OF DRUG THERAPY IN CHRONIC RENAL FAILURE IN GERIATRIC PATIENTS

-OVERVIEW OF DRUG THERAPY IN COPD IN GERIATRIC PATIENTS

-OVERVIEW OF DRUG THERAPY IN CHRONIC CONGESTIVE HEART FAILURE IN GERIATRIC PATIENTS

-OVERVIEW OF TOXICITIES OF DRUG THERAPY IN GASTROENTEROLOGY IN GERIATRIC PATIENTS

-OVERVIEW OF TOXICITIES OF DRUG THERAPY IN PSYCHIATRY IN GERIATRIC PATIENTS

-OVERVIEW OF TOXICITIES OF DRUG THERAPY IN RHEUMATOLOGY IN GERIATRIC PATIENTS

-OVERVIEW OF DRUG THERAPY IN DIABETES MELLITUS IN GERIATRIC PATIENTS

-RELATION OF HIP FRACTURE IN THE ELDERLY TO FLUORIDE TOXICITY

-TOXICITY OF FLUORIDE IN GERIATRIC PATIENTS

-OVERVIEW OF DRUG TREATMENT OF ALZHEIMER’S DISEASE

-OVERVIEW OF DRUG TREATMENT OF OSTEOPOROSIS

-OVERVIEW OF ANTIBIOTIC USAGE AND TOXICITY IN THE ELDERLY

-OVERVIEW OF BETA BLOCKER USAGE AND TOXICITY IN THE ELDERLY

-OVERVIEW OF DIGITALIS USAGE AND TOXICITY IN THE ELDERLY

-OVERVIEW OF THE EMERGENCY PHYSICIAN’S ROLE IN GERIATRIC MEDICINE

-SPECIAL CONSIDERATIONS REGARDING GERIATRICS PATIENTS BROUGHT TO THE EMERGENCY ROOM

-OVERVIEW OF LEGAL, ETHICAL, AND RELIGIOUS CONSIDERATIONS IN CPR OF THE TERMINALLY ILL PATIENT

-THE IMPORTANCE OF KINDNESS, UNDERSTANDING, AND HUMANITY IN GERIATRIC MEDICINE

-THE ROLE OF RELIGION AND RELIGIOUS VALUES IN GERIATRIC MEDICINE

-THE ROLE OF PRAYER IN GERIATRIC MEDICINE