Physician/Clinician FACTS Physician/Educator BreakName* First Last First NameLast NameCredentials*Please select ONLY the highest level of credentialing you have earned. If needed, please use the "Other" text box below to enter additional details. DO - Doctor of Osteopathy ND - Naturopathic Doctor MD - Medical Doctor PhD - Doctor of Philosophy PA-C - Certified Physicians Assistant CNM - Certified Nurse Midwife NP - Nurse Practitioner BSN - Bachelor of Science in Nursing (including RN) FCMC - Fertility Care Medical Consultant FCP - Fertility Care Practitioner HRHP - Holistic Reproductive Health Practitioner NFP/FA-Ed - Natural Family Planning or Fertility Awareness Educator Student - Medical or health professional student Other Other/Additional Details (please specify)Specialty*Please select your practice specialty and/or the methods in which you instruct or educate patients/clients. If needed, please use the"Other" text box below and enter additional details.. Family Medicine Obstetrics/Gynecology Internal Medicine Pediatrics Emergency Medicine General Practitioner Women's Health Billings Ovulation Method Creighton Model/NaPro Technology Family of the Americas FEMM (Fertility Education and Medical Management) Justisse Marquette Method NeoFertility Sympto-Hormonal Methods Sympto-Thermal Methods TwoDay Method Other (please specify) Other/Additional Details (please specify)Personal PhoneInternal use onlyPersonal Email Internal use onlyPictureOffice InformationOrganization or Practice NamePractice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Street AddressCityStateZipcodeCountryPractice PhonePractice Email Practice Website Do you offer telemedicine services?YesNoTemporarily due to the COVID pandemicList State(s) you offer telemedicine servicesDo you offer healthcare services in a language other than English?YesNoList languages you offer healthcare servicesPlease indicate which FABMs you are formally trained in and/or certified to offer Billings Ovulation Method Creighton / NaPro Technology Family of the Americas FEMM Justisse Method Lactational Amenorrhea Marquette Standard Days Sympto-Hormonal Method (please specify in comments) Sympto-Thermal Method (please specify in comments) Two-Day Method Other (please specify in comments) Tained/Certified CommentsPlease indicate which FABMs you are knowledgeable about, i.e. have received some training in and/or engaged in extensive study of the method(s) Billings Ovulation Method Creighton / NaPro Technology Family of the Americas FEMM Justisse Method Lactational Amenorrhea Marquette Standard Days Sympto-Hormonal Method (please specify in comments) Sympto-Thermal Method (please specify in comments) Two-Day Method Other (please specify in comments) FABMs you are knowledgeable CommentsFor medical professionals, do any fertility awareness educators work with you in your practice?YesNoPlease specify the fertility awareness educator that works with youNameEmailMethods trained in For FABM educators, are you affiliated with an FABM medical practice?YesNoPlease specify for FABM that you are affiliated with an FABM medical prcaticeNameEmailMethods trained in If you wish to list additional educators, please add their name, methods trained in and email address in the comment box belowFor medical professionals, do you refer to specific FABM educators?YesNoPlease specify the fertility awareness educator that you referNameEmailMethods trained in For FABM educators, do you refer to specific FABM trained medical professionals?NameEmailMethods trained in If you wish to list additional educators, please add them in the comment box belowAre you interested in being a Professional FACTS Member?I am already a paid Professional FACTS MemberYesNoAre you interested in being a FACTS Preceptor?I am already a FACTS PreceptorYesNoDo you receive our weekly FACTS blog or newsletter that comes out on Wednesdays?NoYesI am not sureOther comments or InformationEmailThis field is for validation purposes and should be left unchanged.