Physician/Clinician FACTS Physician/Educator HiddenBreak Name* First Last HiddenFirst Name* HiddenLast 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. 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 Emergency Medicine General Practitioner Women's Health Adolescents Pediatrics 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 Phone*Internal use onlyPersonal Email* Internal use onlyPictureMax. file size: 64 MB.Office InformationOrganization or Practice Name Practice 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HiddenStreet Address HiddenCity* HiddenState* HiddenZipcode* HiddenCountry Practice Phone*Practice Email* Practice Website Do you offer telemedicine services?*YesNoTemporarily due to the COVID pandemicList State(s) you offer telemedicine services Do you offer healthcare services in a language other than English?*YesNoList languages you offer healthcare services Please 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 NeoFertility Standard Days Sympto-Hormonal Method (please specify in comments) Sympto-Thermal Method (please specify in comments) Two-Day Method Other (please specify in comments) Trained/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 NeoFertility 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.