New Panel Request

To request a panel at your institution, fill in the required information and submit your online request. Or download the PDF version and follow the instructions.

New Panel Request Form PDF

Contact Person

First Name

Last Name

Phone

(###)

###

####

Does your facility meet LAHIC criteria?

“Facilities that meet our panel requirements are places where the patients do not have access to outside meetings.” (Policy Guidelines, pg. 25)

Requested Panel Day/Time

Panel Address

Where will the meetings happen?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country