Add Care Specialist - DSC ALLIANCE

Supporter Application Form For DSC Alliance

This information will be used to build internal and public directories of DSC Alliance members.Your information will NEVER be shared or sold to third-parties. If you have any questions, please feel free to contact us to discuss.

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Your Details

Name *

Enter your name.

Email *

Enter your email address.

Enter Listing Details

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Package

Annual Plan – 420$

Select your package.

Are you a specialist physician practicing or interested in direct care model? *

Yes

First and Last Name (as displayed professionally) *

National Provider Identification Number *

Medical School Graduate *

Medical Degree (MD/DO/DPM) *

Year of Graduation *

Residency Training Program *

Fellowship Program/ specialty *

Default Category *

The default category can affect the listing URL and map marker.

Name and address of your current practice

Name of your current practice

Address of your current practice *

Please enter the listing street address. eg. : 230 Vine Street

Country *

Click on above field and type to filter list.

State *

Click on above field and type to filter list or add a new region.

City *

Click on above field and type to filter list or add a new city.

Zip/Post Code

Please enter listing Zip/Post Code

Click on “Set Address on Map” and then you can also drag map marker to locate the correct address

Contact Information

Phone

Fax

Website

Add the Full https://yourwebsite.com

Email *

Preferred email

What is your preferred email? This will be stored in the directory, not listed on the website. You will receive important announcements from the DSC Alliance and will not be shared with third parties without your agreement.

What is the best way to get in contact with you?

Email/ phone/ text message?

The year of starting/planning to start your DSC practice?

Do you agree to have your practice listed on the DSC Alliance website? *

Yes

About Me

About

Photo

Drop files here

Allowed file types: .jpg, .jpe, .jpeg, .gif, .png, .bmp, .ico, .webp, .avif

(You can upload unlimited files with this package)

Please drag & drop the files to rearrange the order

Type 64 into this box

Preview Listing

Supporter Application Form For DSC Alliance

Your Details

Enter Listing Details

Name and address of your current practice

Contact Information

About Me

Receive DSC Alliance News

Quick Links

contact us