3Greens New Pilot Info Request Form and Application

First Name

Last Name

Degree (MD, DO, RN, etc)

mobile #

City, State

Employer

Primary Hospital

Specialty

Which medical/surgical societies are you a member? (SRS, etc)

Preop Checklists

Preop Conferencing / Team Review

Intra-Op Checklists

Postop Checklists

Timer / Efficiency Tracking

Teamwork Enhancement

Operating room Flow Analysis

Personal Registry Data Collection

Registry Data Collection for National Registries

Burnout prevention / work-life balance

Improving Clinic Efficiency and Flow

Analytics / Dashboards

Other (please specify)

Sun Afternoon

Sun Eve

Mon Eve

Wed Eve

Thu Eve

Saturday AM

Saturday Afternoon

Thank you for sending your request. We will be back in touch shortly. The 3Greens Flight Support Team. support@3Greens.com, or Lloyd.Hey@3Greens.com