Unique IDName(Required) English only pleaseDate of Birth(Required) DD slash MM slash YYYY Specialty(Required)Infectious DiseaseOncologyThoracic surgeryAnesthesiaCardiac SurgeryCardiovascular MedicineDentistryDermatologyEmergency medicine (Eligible board specialist)Emergency medicine specialistEndocrinologyGastroenterologyGeneral PediatricsGeneral RadiologyGeneral SurgeryGPHematologyImmunology RheumatologyInternal MedicineNephrologyNeurologyNeurosurgeryObstetrics & GynecologyOrthopedicOtolaryngology- Head & Neck SurgeryPediatric SurgeryPlastic SurgeryPulmonary Medicine ServiceUrologyVascular SurgeryPhone(Required) Clinic Phone Email Address(Required) City State / Province / Region DocumentPersonal photo(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 1. CV Drop files here or Select files Max. file size: 5 MB, Max. files: 4. Covid Vaccine Certificate Drop files here or Select files Max. file size: 3 MB, Max. files: 1. National Identity(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 2. Bachelor's Certificate Drop files here or Select files Max. file size: 5 MB, Max. files: 1. M.O.H License for Specialty(Required) Drop files here or Select files Max. file size: 7 MB. Jordan Medical Association Registration(Required) Drop files here or Select files Max. file size: 7 MB. Board Certification Jordan-Arab(Required) Drop files here or Select files Max. file size: 7 MB. Additional Certificates Drop files here or Select files Max. file size: 10 MB. Publications Drop files here or Select files Max. file size: 5 MB. Privilege's(Required)Infectious DiseaseOncologyThoracic surgeryAnesthesiaCardiac SurgeryCardiovascular MedicineDentistryDermatologyEmergency medicine (Eligible board specialist)Emergency medicine specialistEndocrinologyGastroenterologyGeneral PediatricsGeneral RadiologyGeneral SurgeryGPHematologyImmunology RheumatologyInternal MedicineNephrologyNeurologyNeurosurgeryObstetrics & GynecologyOrthopedicOtolaryngology- Head & Neck SurgeryPediatric SurgeryPlastic SurgeryPulmonary Medicine ServiceUrologyVascular Surgery Privileges in Infectious Disease PDF VIEW Open a PDF file Privileges in Infectious Disease. for any additional privileges insert it at next field Privileges in Oncology PDF VIEW Open a PDF file Privileges in Oncology. for any additional privileges insert it at next field Privileges in Thoracic Service PDF VIEW Open a PDF file Privileges in Thoracic Service. for any additional privileges insert it at next field Privileges in Anesthesia PDF VIEW Open a PDF file Privileges in Anesthesia. for any additional privileges insert it at next field Privileges in Cardiac Surgery PDF VIEW Open a PDF file Privileges in Cardiac Surgery. for any additional privileges insert it at next field Privileges in Cardiovascular Medicine PDF VIEW Open a PDF file Privileges in Cardiovascular Medicine. for any additional privileges insert it at next field Privileges in Dentistry Service PDF VIEW Open a PDF file Privileges in Dentistry Service. for any additional privileges insert it at next field Privileges in Dermatology Service PDF VIEW Open a PDF file Privileges in Dermatology Service. for any additional privileges insert it at next field Clinical Privileges in Emergency medicine specialist PDF VIEW Open a PDF file Clinical Privileges in Emergency medicine specialist. for any additional privileges insert it at next field Clinical Privileges in Emergency medicine (Eligible board specialist) PDF VIEW Open a PDF file Clinical Privileges in Emergency medicine (Eligible board specialist). for any additional privileges insert it at next field Privileges in Endocrinology Service PDF VIEW Open a PDF file Privileges in Endocrinology Service. for any additional privileges insert it at next field Privileges in Gastroenterology PDF VIEW Open a PDF file Privileges in Gastroenterology. for any additional privileges insert it at next field Privileges in General Pediatrics PDF VIEW Open a PDF file Privileges in General Pediatrics. for any additional privileges insert it at next field Privileges in General Radiology PDF VIEW Open a PDF file Privileges in General Radiology. for any additional privileges insert it at next field Privileges in General Surgery PDF VIEW Open a PDF file Privileges in General Surgery. for any additional privileges insert it at next field Clinical Privileges in GP PDF VIEW Open a PDF file Clinical Privileges in GP. for any additional privileges insert it at next field Privileges in Hematology Service PDF VIEW Open a PDF file Privileges in Hematology Service. for any additional privileges insert it at next field Privileges in Immunology Rheumatology Service PDF VIEW Open a PDF file Privileges in Immunology Rheumatology Service. for any additional privileges insert it at next field Privileges in Internal Medicine PDF VIEW Open a PDF file Privileges in Internal Medicine. for any additional privileges insert it at next field Privileges in Nephrology PDF VIEW Open a PDF file Privileges in Nephrology. for any additional privileges insert it at next field Privileges in Neurology Service PDF VIEW Open a PDF file Privileges in Neurology Service. for any additional privileges insert it at next field Privileges in Neurosurgery Service PDF VIEW Open a PDF file Privileges in Neurosurgery Service. for any additional privileges insert it at next field Privileges in Obstetrics & Gynecology Service PDF VIEW Open a PDF file Privileges in Obstetrics & Gynecology Service. for any additional privileges insert it at next field Privileges in Orthopedic PDF VIEW Open a PDF file Privileges in Orthopedic. for any additional privileges insert it at next field Privileges in Otolaryngology- Head & Neck Surgery Service PDF VIEW Open a PDF file Privileges in Otolaryngology- Head & Neck Surgery Service. for any additional privileges insert it at next field Privileges in Pediatric Surgery PDF VIEW Open a PDF file Privileges in Pediatric Surgery. for any additional privileges insert it at next field Privileges in Plastic Surgery PDF VIEW Open a PDF file Privileges in Plastic Surgery. for any additional privileges insert it at next field Privileges in Pulmonary Medicine Service PDF VIEW Open a PDF file Privileges in Pulmonary Medicine Service. for any additional privileges insert it at next field Privileges in Urology Service PDF VIEW Open a PDF file Privileges in Urology Service. for any additional privileges insert it at next field Privileges in Vascular Surgery Service PDF VIEW Open a PDF file Privileges in Vascular Surgery Service. for any additional privileges insert it at next fieldAdditional Privileges Add RemoveNoteConsent(Required) I agree toI confirm that the all files and information attached above are complete and correct. I authorize the hospital to verify them according to the instructions and regulations in the hospital, and I sign on all the above.Signature(Required)PDF Preview
