1. Contact person

Contact name:	Dr. Mr. Ms. Mrs.
Title:
Practice name:
Phone:	Ext.:
Fax*:
E-mail*:
Address:
City:	State: Zip:

*E-mail and fax are required. Our communication is conducted via e-mail, and secondarily, by fax. We do not give your contact information to other businesses without your permission.

2. Your name if different from above

Name:	Dr. Mr. Ms. Mrs.
Title:
Phone:	Ext.:
E-mail:

3. How did you hear about us?

Web search:     Google     AOL     Other search engine
Direct mail
Ad on a health information website published by Healthcommunities.com
Link from another website:
Referred by another practice:
Other:

4. Website link options

You do not need a website to be listed in MDLocator, but providing a link to more information on a practice website is the best way to achieve the full value of your listing.

Please select one:
Link to our current website:
Please create a basic one-page website for us, for an additional $2/month or $24/year.*
We do not have or want a website, but list our names, addresses, and main phone number in MDLocator.

*NOTE: Full-Service Medical Website Design is available separately. (Link opens in new window.)

5. Locations

We will list the doctors in your practice in MDLocator under all applicable zip codes. Therefore, providing an accurate and complete location list is important.

Please select one:
A complete list of our current locations is listed on our website.
We only have the location(s) listed below.
We will e-mail the complete list of locations later.
Some doctors only see patients at certain locations. We will e-mail the complete list later, indicating which doctors go to which locations.

Main address:
City:		State:		Zip:
Phone:
Fax:
2nd address:
City:		State:		Zip:
3rd address:
City:		State:		Zip:

6. Practitioner Information

Practitioner Name (including MD, DO...)	E-mail Address	Primary Specialty (e.g., urology)	Board Certified

7. Billing Options

Please select one:
Yearly credit card
Monthly credit card
Yearly invoicing
Coupon code:

We will send your bill or other payment information after we receive this enrollment form.