Practice Information (This information will be available for viewing on the web) |
Please enter information about your practice exactly as you would like it to appear in the directory.
Bold, red items are required. Unbold, green items are requested. |
Practice Name: |
|
Enter the name of your practice. |
Physical Address: |
|
This is the address you give to your clients when they want to come and see you. |
Postal Address: |
|
Use this only if your mailing address is different from the above address. An example would be PO Box 123 |
City / State / Zip: |
|
|
County / Country: |
|
|
Phone / Fax: |
|
Please use the format 999.999.9999 X-9999 |
Specialty: |
|
Select the predominant choices for your practice or add a new specialty. |
New Specialty: |
|
Email: |
|
Required so directory administrator can reach you. Not required to allow any other use. |
Practice URL |
|
On-line address of your practice web site. If you do not have one then type "NONE" |
|
Picture URL: |
OR
|
If you have a web address for a picture of you put it here. This should be a link directly to the picture itself. |