Patient / Physician Matching System : Physician Registration

(Note: If you have more than one practice location, you'll be able to add locations after your information has been verified and application has been approved.)

Doctor Application Form
First Name:		Last Name:
Name Suffix: (Ex. Jr, III)		Professional Suffix: (M.D., F.A.S.A.M)
Street Address:	(Please enter the physical address of your main practice)
	(Suite/Office #)
City:		State:		Zip:
Phone:	( ) - (Number that selected patients will be asked to call)	Email:	(No patient will see this e-mail address, it is for notification by NAABT only)
DEA # (Last 4 Digits):		Password:
Receive an e-mail alert when new patients register:	Yes No	Confirm Password:
I Agree to Terms: