Wake Fo
rest Baptist Health Wake
Forest University School of Medicine
Department of Radiology
Medical Center Boulevard
Winston-Salem, North Carolina 27157-1088
ATTACH RECENT
PHOTO HERE
Application for Fellowship in:
Nuclear Radiology
Cardiothoracic Imaging
Proposed
Beginning Date of Training: Visa Status (if applicable)
Full Name:
Present Address:
Street
City/State
Postal Code
Telephone:
Daytime
Evening
Email
Social Security # Citizenship:
Place of Birth: Date of Birth:
Government Obligations (Public Health Services, etc.)
Premedical Education (List Colleges, Degrees and Dates)
Medic
al School and Dates:
Achievements (Awards, Honorary Societies, etc.):
Post-Doctoral E
xperience (Internship, Residency, Fellowship, Private Practice and Dates):
Publications:
Pro
fessional plans after fellowship program:
Teaching
Private practice
Generalist
Research
Specialist
Stat
es in which you have a full active medical license:
If you answer yes to any of the following questions, please give full details on a separate sheet.
Yes No
1. Has your license to practice medicine in any jurisdiction ever been limited, suspended, or
revoked?
2. Have you ever been refused membership in a hospital medical staff?
3. Has your request for any specific clinical privileges ever been denied or granted with stated
limitations?
4. Have your privileges at any institution ever been limited, restricted, or revoked?
5. Has your narcotics registration ever been suspended or revoked?
6. Have you ever been denied membership or renewal thereof, or been subject to disciplinary
action, in any medical organization?
7. Have you been diagnosed with or do you have a medical condition that limits or impairs your
ability to practice medicine?
8. Have you engaged in the use of any chemical substance(s) that in any way interfered with your
abilities to practice medicine?
Name, Address and Telephone
Number of Radiology Residency Program Director:
In support of this application, please s
ubmit:
•
Letter of recommendation from the Director of your Residency Program
•
Two additional letters of recommendation
The information contained herein is true to the best of my knowledge and belief.
Signature of Applicant: Date:
Enclosures: Curriculum Vitae
Personal Statement
Completed applications should be mailed to the appropriate fellowship director at the address
listed belo
w:
Wake Forest University School of Medicine
Department of Radiology
Medical Center Boulevard
Winston-Salem, North Carolina 27157-1088
Cardiothoracic Imaging: Janardhana Ponnatapura, M.D.
Nuclear Radiology: Yong Bradley, M.D.
Fellowship Application Form Revised: January 16, 2024
Copyrigh
t: All rights reserved. Wake Forest
University School of Medicine Department of
Radiology Medical Center Boulevard Winston-
Salem, NC 27157
