FACTS Physician/Educator

Hidden

Break

Name*

First Last

Hidden

First Name*

Hidden

Last Name*

Credentials*

Please select ONLY the highest level of credentialing you have earned. If needed, please use the "Other" text box below to enter additional details.

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..

Other/Additional Details (please specify)

Personal Phone*

Internal use only

Personal Email*

Internal use only

Picture

Max. file size: 64 MB.

Office Information

Organization or Practice Name

Practice Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Street Address

Hidden

City*

Hidden

State*

Hidden

Zipcode*

Hidden

Country

Practice Phone*

Practice Email*

Practice Website

Do you offer telemedicine services?*

List State(s) you offer telemedicine services

Do you offer healthcare services in a language other than English?*

List languages you offer healthcare services

Please indicate which FABMs you are formally trained in and/or certified to offer

Trained/Certified Comments

Please indicate which FABMs you are knowledgeable about, i.e. have received some training in and/or engaged in extensive study of the method(s)

FABMs you are knowledgeable Comments

For medical professionals, do any fertility awareness educators work with you in your practice?

Please specify the fertility awareness educator that works with you

Name	Email	Methods trained in

For FABM educators, are you affiliated with an FABM medical practice?

Please specify for FABM that you are affiliated with an FABM medical prcatice

Name	Email	Methods trained in

If you wish to list additional educators, please add their name, methods trained in and email address in the comment box below

For medical professionals, do you refer to specific FABM educators?

Please specify the fertility awareness educator that you refer

Name	Email	Methods trained in

For FABM educators, do you refer to specific FABM trained medical professionals?

Name	Email	Methods trained in

If you wish to list additional educators, please add them in the comment box below

Are you interested in being a Professional FACTS Member?

Are you interested in being a FACTS Preceptor?

Do you receive our weekly FACTS blog or newsletter that comes out on Wednesdays?

Other comments or Information

Name

This field is for validation purposes and should be left unchanged.

Physician/Clinician

FACTS Physician/Educator

Office Information

Pin It on Pinterest