R
Home
CME
Contact Us
User Registration
Personal Details
*
First Name
Middle Name
*
Last Name
*
Are you a: Individual OR Clinic
?
Individual
Clinic
*
Email
*
Affiliation:
*
Password
(Minimum 8 characters with at least 1 Number)
*
Confirm Password
Contact Details
Address 1
Address 2
Country
-- Select --
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belice
Belize
Benin
Bermuda
Bhutan
Bolivia
Botswana
Bouvet Island
Brasil
Brazil
Bulgaria
Burkina Faso
Burundi
CACM
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faeroe Islands
Fiji
Finland
France
Francés de Guayana
French Guiana
Gabon
Gambia
Germany
Ghana
Gibraltar
Greece
Grenada
Guadeloupe
Guam
Guatemala
Guayana
Guinea
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Latvia
Lebanon
Lesotho
Libaria
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mexico
México
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Nordic countries
Norfolk Island
Norway
Oman
Other
Pakistan
Palau
Panama
Panamá
Papua New Guinea
Paraguay
Peru
Perú
Philippines
Pitcairn
Poland
Portugal
Qatar
Reunion
Romania
Russian
Rwanda
Saint Lucia
Samoa Western
San Marino
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syrian Arab
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
UK
Ukraine
United Arab Emirates
Uruguay
USA
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands
Western Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
State
-- Select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Other
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
City
Zip Code
Phone
Fax
Additional Details
*
Degree
-- Select --
APN
ARNP
BS
BSN
CRNA
DO
DPM
DSN
DTR
LPN
MD
MD, PhD
MD, RPh
MHA
MS
MSN
NP
OD
Other
PA
PA-C
PharmD
PhD
RCIS
RD
RN
RPh
RRT
RT
*
Specialty
-- Select --
Allergy/Immunology
Anesthesiology
Cardiology
Critical/Intensive Care
Dentistry
Dermatology
Emergency Medicine
Endocrinology
ENT/Otolaryngology
Family/General Practice
Gastroenterology
Geriatrics
Hematology
Hospital Medicine
Infectious Disease
Internal Medicine
Long Term Care
Managed Care
Nephrology
Neurology
Nutrition
Obstetrics and Gynecology
Oncology
Ophthalmology
Optometry
Orthopedics
Other
Otolaryngology
Pain Management
Pathology
Patient Education
Pediatrics
Pharmacy
Physiatrists/Rehab Medicine
Podiatry
Psychiatry
Pulmonology
Radiology
Respiratory Therapy
Rheumatology
Sleep Medicine
Surgery
Urgent Care
Urology
*
Practicing Type
-- Select --
Case Manager
Dentist
Diabetes Educator
Dietitian
Fellow
Industry
Nurse
Nurse Anesthetist
Nurse Practitioner
Other
Pharmacist
PharmTech
Physician
Physician Assistant
Researcher/Scientist
Resident
Respiratory Therapist
RT
School Nurse
Staff
Provider NPI
Name of Practice
*
Practice Setting
-- Select --
Ambulatory
Hospital
Long-term care facility
Other
ABIM ID
?
ABIM DOB (mm/dd)
Type/Size of Practice
-- Select --
Long Term
Short Term
*
How many of the clinicians in your practice are routinely involved in the diagnosis and management of patients with CIC?
?
*
How many patients with suspected or diagnosed CIC are seen in your institution each month?
?
Board Certifications (Optional):
AFM ID Number
ABP ID Number
I agree to accept all term and conditions
How many hours each week (on average) to you spend caring for patients at this facility?
Relation With Facility:
Private physician from the community
Contracted/ Employed by the facility
Privileges Only
Number of Years In Practice:
1-5
5-10
10-15
>16
Number of Patients Seen Weekly:
1-25
26-50
51-100
>100
Submit
Cancel