Doctor Registration Form
	User Name*		Password*
	First Name*		Last Name*
	Email*		Phone*
	Practice Name*
	Service	Medical Dental Chiropractic Accupuncture Vision / Hearing Podiatrist Counseling / Therapist Suppliers
	Speciality	General Practice Family Phyician Internal Medicine Pediatrics OB/Gyn Allergy & Immunology Anesthesiology Cardiology Cardiology - Interventional Cardiovascular Disease Clinical Neurophysiology Colon and Rectal Surgery Dermatology Dermatology - Micrographic Surgery Dermatopathology Ear, Nose and Throat Ear, Nose and Throat - Head and Neck Plastic Surgery Electrophysiology Emergency Medicine Endorinology GastroenterologyGeriatric Medicine Gynecologic Oncology Gynecologic Medicine Gynecologic Surgery Gynecology Hematology & Oncology Infectious Disease Maternal & Fetal Medicine Medical Genetics Nephrology Neurologic Surgery Neurology Nuclear Medicine Nuclear Medicine - In Vivo & In Vitro Orthopedic Orthopedic Surgery Pain Management Pathology Pediatrics - Adolescent Medicine Pediatrics - Allergy & Immunology Pediatrics - Cardiology Pediatrics - Critical Care Pediatrics - Ear, Nose and Throat Pediatrics - Emergency Medicine Pediatrics - Endocrinology Pediatrics - Gastroenterology Pediatrics - Hematology & Oncology Pediatrics - Infectious Disease Pediatrics - Neonatology Pediatrics - Neonatology & Perinatolgy Pediatrics - Nephrology Pediatrics - Neurology Pediatrics - Pathology Pediatrics - Pulmonology Pediatrics - Rehabilitation Medicine Pediatrics - Rheumatology Pediatrics - Surgery Physical Medicine & Rehabilitation Plastic Surgery Plastic Surgery - Head and Neck Preventive Medicine - Occupational Psychiatry Psychiatry - Child & Addolescent Psychiatry - Geriatric Pulmonary Disease Radiation Oncology Radiology Reproductive Endocrynology & Infertility Rheumatology Sports Medicine SurgerySurgery - Critical Care Surgery - Hand Surgery Surgery - Oral & Maxilliofacial Surgery - Thoracic Surgery - Vascular Urology
	Practice  Summary  Description
	*Indicates a mandatory field