May 9, 2008, 12:19 pm

Doctor Registration

In order to ensure the highest possible quality of our database, we contact each and every new registrant for verification purposes. We will try to reach you directly at the telephone numbers you have entered during your registration. Please ensure that you give us accurate and current contact information.

Following a successful verification, you will be granted a free, permanent access to the benefits that our paying members enjoy.

Priority Code:	(Optional)
Prefix (Dr., etc.):	(Optional)
First name:
Last name:
Please choose your specialization:	Other:
Email Address:
Country:
State:
City: (Optional) (If you cannot find your city above.)
Address:

Postal Code:
Telephone (Business):
Telephone (Residence):	(Optional)
Telephone (Cell):	(Optional)
Fax:	(Optional)
Username: (For free access to our Members' Area)
Passcode: (For free access to our Members' Area)	(8 or more characters and/or numbers.)
Confirm Passcode:
Secret question/answer:
How many patients with CMT do you see each year?
Are you interested in being listed in our searchable doctor database for patients with CMT and other Hereditary Neuropathies? (Listing is free of charge.)
Do you order genetic testing for CMT?
Your Local time:	(Please choose time difference from May 9, 2008, 12:19 pm.)