Histiocytosis Association Physicians Directory Application
Thank you for your interest in becoming a part of our Online Physicians Directory. By filling out this form, you consent to have the general information requested (EXCEPT email address) made available to patients who reach out to the Histiocytosis Association seeking physicians in their area. Your email address will NOT be provided. Acceptance into the Physicians Directory does not constitute a recommendation or referral on behalf o the Histiocytosis Association. The information is provided to our online community for informational purposed only.

Should any of your information change or you have any questions, please reach out to us at outreach@histio.org so that we can ensure the most current information is always available.
Title *
Your answer
First Name *
Your answer
Last Name *
Your answer
Professional Suffix (MD, PhD, etc.) *
Your answer
Department *
Your answer
Position *
Your answer
Institution/Hospital *
Your answer
Country *
Your answer
Address *
Your answer
City *
Your answer
State *
If not applicable, enter N/A in the space provided
Your answer
Zipcode *
If not applicable, enter N/A in the space provided
Your answer
Telephone Number for Patients To Make Appointment *
Your answer
Email Address (for our internal use only - not public) *
Your answer
Are you a Member of the Histiocyte Society *
Approximate number of patients you've treated or are currently treating with histiocytic disorders: *
Your answer
Which of the following histiocytic disorders are you able and willing to treat? *
Adults
Pediatric
Do Not Treat
Langerhans cell histiocytosis
Hemophagocytic lymphohistiocytosis
Pulmonary Langerhans cell histiocytosis
Rosai Dorfman Disease
Erdheim Chester Disease
Xanthogranuloma
Diabetes Insipidus
What is your specialty? *
Required
Any additional information you would like us to know about you or your institution (in relation to the treatment of histiocytic disorders)
Your answer
Please send me information about the Histiocytosis Association *
The Histiocytosis Association is a global nonprofit organization dedicated to addressing the unique needs of patients and families dealing with the effects of histiocytic disorders while leading the search for a cure.
Please send me information about the Histiocyte Society *
The Histiocyte Society is a group of more than 200 physicians and scientists from around the world committed to improving the lives of patients with histiocytic disorders by conducting clinical and laboratory research into the causes and treatment of this disease.
Submit
Never submit passwords through Google Forms.
This form was created inside of Histiocytosis Association. Report Abuse