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Healthcare Provider Directory
Contact Information
Name
*
Prefix
First Name
Last Name
Suffix
I hold the following degree(s)
*
Please check all that apply
MD
DO
PhD
MBBS
ChB
Other
Other Degree(s)
Organization
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Country
Email
*
Although we are requesting this information, we will not be publishing your email address.
Verify Email
*
Phone
*
Website (enter n/a if you don't have a website)
*
Specialty
*
Please check all that apply
Sleep medicine
Neurology
Pulmonary/critical care
Psychiatry
Otolaryngology
Internal medicine
Pediatrics
Family medicine
Anesthesiology
Other
Other Specialties
I treat patients with the following conditions
*
Please check all that apply
Idiopathic hypersomnia
Kleine-Levin syndrome
Narcolepsy
None of the above
Number of patients (new and returning) I treat in a month with idiopathic hypersomnia
*
select one
0
1-5
6-10
11-15
16-20
21+
Number of patients (new and returning) I treat in a month with Kleine-Levin syndrome
*
select one
0
1-5
6-10
11-15
16-20
21+
Number of patients (new and returning) I treat in a month with narcolepsy
*
select one
0
1-5
6-10
11-15
16-20
21+
I am accepting new patients
*
select one
Yes
No
I treat
*
select one
Children
Adults
Children and adults
I conduct clinical research on hypersomnia
*
select one
Yes
No
By submitting this form, I agree to have my information added to the Hypersomnia Foundation's Healthcare Provider Directory. I understand that inclusion in the directory does not imply endorsement by the Hypersomnia Foundation.
*
I agree
I do not agree
I would like to receive complementary brochures from the Hypersomnia Foundation to distribute in my office.
*
Yes
No
How many brochures do you expect to distribute within the next 6 months?
*
I would like to receive complementary IH medical alert cards from the Hypersomnia Foundation to distribute in my office.
*
Yes
No
How many cards do you expect to distribute within the next 6 months?
*
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