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发表于 2012-1-11 11:39
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9 C: o u! h: j# NPhysician Information+ R- ]" l: d) O' A% `
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Postal Code
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(first 3 digits only)
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Language Spoken (other than English)
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Select One...AfrikaansAlbanianAmharicArabicArmenianAshantiAssyrianBengaliBicolanoBulgarianBurmeseCantonese (China)ChineseCoorgiCreeCroatianCzechDanish (Denmark)DutchEsperanto (International Language)EstonianFarsiFijianFilipino (Philippines)FinnishFlemishFrenchGaelic (United Kingdom)GermanGreekGujarati (India)Gujerati (India)Haitian CreoleHausaHebrewHindiHungarianIboIcelandicIgboIndonesianIrishItalianJapaneseKachiKanarKannadaKhmerKiswahiliKoreanKurdish (Kurmanji / Kurdi)KutchhiLatvianLithuanianMacedonianMalay (Malaysia)Malayalam (India)Maltese/Italian (Malta)Mandarin (China)Marathi (India)Mauritian (Africa)MelanesianNorwegianPakistaniPashtuPersian (Farsi)PolishPortuguesePunjabiPunjabi (India)Romanian/RumanianRussianSaraiki (or Seraiki)SerbianSerbo-CroatianSetswanaShona (Africa)SidhiSign LanguageSindhiSinhalese (Sri Lanka)SiswatiSlovakSlovenianSothoSpanishSwahili (Africa)SwedishTagalog (Philippines)TaiwaneseTamil (India)Telegu (India)Toy-sun-eseTswanaTurkishUkrainianUrdu (Pakistan/India)VietnameseWelshXhosaYiddishYoruba (Africa)Zulu (Africa)6 |, w6 G& T. m, `. i5 J* f N+ O: }
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First Name (if known):
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Select One...AcupunctureAnti-Aging Medicine (Complementary)Ayurveda (Complementary)Bio-Identical Hormone Therapy (Complementary)CCT-Level 2CCT-Level 3Cardiac Nuclear ImagingCardiac Stress TestingCarotid DopplerCertified ExaminerChelation Therapy (Complementary)Chinese Medicine (Complementary)Customized Nutritional Therapy (Complementary)Echocardiography - Full AdultEchocardiography - Full PediatricEchocardiography - RestrictedEchocardiography - TransesophagealElectrocardiogramElectroencephalographyElectromyographyEvoked Potential (EP)Evoked Potential VisualFluoroscopically-guided needle placementsFunctional Medicine (Complementary)Hair TransplantationHerbal Therapy (Complementary)Homeopathy (Complementary)Injury Management ConsultantIntegrative Medical Assessments (Complementary)Longevity Medicine (Complementary)Low Intensity Laser Therapy for the Treatment of Musculoskeletal Disorders (Complementary)Magnetic Resonance - CardiacMagnetic Resonance - FullMagnetic Resonance - LimitedNuclear Medicine - FullNuclear Medicine - LimitedNuclear Medicine - RestrictedOral Chelation Therapy for Autism (Complementary)PET - Positron Emission TomographyPrimordial Sound Meditation (Complementary)Pulm Director - Level IIPulm Director - Level IIIPulm Director - Level IVPulm Interpretation-Level IIPulm Interpretation-Level IIIPulm Interpretation-Level IVRegenerative Medicine (Complementary)Reiki Therapy (Complementary)Resident Approval - Mental Health CertificatesSleep Director - FullSleep Director - Pediatric DisordersSleep Director - Respiratory DisordersSleep Interpreter - Respiratory DisordersThermography to Assess Chronic Pain (Complementary)Transcendental Meditation (Complementary)Transcranial DopplerUltrasound - FullUltrasound - Obstetrical/GynecologyUltrasound - OpthalmologyUltrasound - UrologyUltrasound - VascularVestibular Testing - DirectorVestibular Testing - Interpretor# w- d- Z: U- M. d
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+ u6 f# N) y" J7 u' G5 B% V( XSelect One...Addiction MedicineAdolescent MedicineAllergiesAllergies - Upper Respiratory TractArthroscopic and Reconstructive Joint SurgeryArthroscopic and Reconstructive Surgery (Knee/Shoulder)Aviation MedicineBreast MedicineBreastfeedingBurn SurgeryCardiac Rhythm Distrubances and Pacemaker TherapyChemical, Biological, Radiological and Nuclear Warfare MedicineChild and Adolescent PsychiatryChild and Maternal HealthChronic Pain ManagementColon & Rectal SurgeryCounselingCritical Care MedicineDermatopathologyDiabetesDiseases of ChildrenDiseases of the EyeDiseases of the JointsDiseases of the KidneyEmergency CareEndocrinologyExercise MedicineForensic PsychiatryForensic Psychiatry & Medico-legal MedicineGeriatric MedicineGeriatric PsychiatryGlaucomaHead and Neck OncologyHead and Neck SurgeryHypnotherapyJoint Replacement & ReconstructionKnee & Leg SurgeryKnee SurgeryLaser SurgeryMaternity Care & Diseases of FemalesMedical GeneticsMental HealthNeonatologyNeuro-ophthalmologyNeuro-otologyNeuroanesthesiaNon-Spine Musculoskeletal ConditionsNutritionNutrition and Weight ManagementObstetrics & GynecologyOccupation Related Medical DisordersOccupational & Aviation MedicineOccupational & Organizational PsychiatryOccupational MedicineOccupational Orthopedics & Clinical ImpairmentOculo-PlasticsOncological Surgery of the Liver and PancreasOrthopedic & Sports Medicine in ChildrenOrthopedic Disability AssessmentOrthopedic TraumatologyPain ManagementPediatric & Adolescent GynecologyPediatric Ophthamology & Adult StrabismusPediatric OrthopedicsPediatric OtolaryngologyPediatric RheumatologyPediatric Sport and Exercise MedicinePerinatologyPhlebologyPhlebology/SclerotherapyPsychiatryPsychological DisordersPsychotherapyPsychotherapy: Individual, Family, & MaritalRepetitive Transcranial Magnetic StimulationReproductive EndocrinologySclerotherapy of Varicose VeinsShoulder SurgerySkin DisordersSleep Disorders MedicineSpeech and Hearing DisordersSport MedicineTravel MedicineUro-oncologyUrogynecology6 X8 Y/ s7 q x
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