American Academy of Family Physicians
About UsNews & PublicationsMembersCME CenterClinical & ResearchPractice MgmtPolicy & AdvocacyCareers

Permissions Request Form

Contact Information

Name:
Address:
City:
State:
Postal Code:
Phone:
Fax:
Email:
Institution / Company Name:


For Profit
Not for Profit

Please check all that apply:
Managed Care Plan (HMO, PPO, POS, etc)
Pharmaceutical
Medical School/ University/ Residency
Education Firm
Physician Office/Group Practice
Ad Agency
Publishing Company
Other:
If yours is a not-for-profit organization, is there sponsorship associated with your project?

Yes
No

If yes, by what organization?

Content you wish to use:

Title:
Publication date:
Page number(s):
Entire article
Table/ Figure
Illustration/ Photograph/ Radiograph
Please identify the material you wish to use:
(Ex: Figure 1 or Table 1 or a specific section)
Publication title and/or web address:
(Ex: "Abnormal Uterine Bleeding" patient information handout http://familydoctor.org/handouts/470.html)

Journal Volume:
Issue Number:

Intended use of AAFP content

Photocopy for Presentation/ Syllabus
Reprint ( in book/ journal/ magazine/ newsletter
CD-ROM
Internet
Translations
List languages:
Other:
Requester's publication title:
Publisher:
Distribution:

Copyrights and Permissions
Shop Catalog