Name (please include any designations): *

What is your birthdate? *

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Where do you practice? *

Email address: *

Please provide any Instagram or Twitter handles below (and include which platform they relate to):

What factors led to your career path? *

Who was your mentor and how did he/she influence your career? *

What are the key attributes that make you one of SpineLine's 20 Under 40? *

What are you most proud of at this stage of your career? *

What is your philosophy of care? *

How do you give back to your local community?

In what ways have you been involved with NASS? *

What do you do with your free time? *

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