MdDS Foundation Professional Directory Opt-in Form
Please enter your information exactly as you would like it to appear in the Professional Directory on mddsfoundation.org, a publicly available resource. Email addresses will not be publicly displayed. Inclusion in our Professional Directory is at the discretion of the MdDS Foundation.
Title
Dr., Mr/Ms, Prof., etc.
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First Name *
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Last Name *
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Specialty *
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Business Name (Practice Name)
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Business Name 2 (Department)
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Address *
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Level, suite, room, etc.
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City *
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State/Province/Region *
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Country *
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Postal Code *
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Telephone Number *
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Email Address (will not be publicly displayed) *
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By providing your email address, you will occasionally receive emails (approximately quarterly) from connect@mddsfoundation.org. We use MailChimp to deliver our newsletters. By submitting this form, you acknowledge that the information you provide will be transferred to MailChimp for processing in accordance with their Privacy Policy and Terms (https://mailchimp.com/legal/privacy/ and https://mailchimp.com/legal/terms/).
Check to have brochures or quick reference cards on Mal de Débarquement Syndrome sent to the address above.
Check to Opt-out of our publicly listed Professional Directory.
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