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Chris Smith Today's Date: mm/dd/yyyy  Add Doctor or Other Healthcare Professional First name: Last name: Title: Select Health Care Role Physican (M.D. or D.O.) Nurse practitioner Nurse Physical therapist Mental health worker Optometrist Podiatrist Midwife Dentist Chiropracter Accupuncturist Herbalist Other Specialty (physicians only): Select Specialty Allergy / Immunology Anesthesiology Cardiovascular Disease Colon / Rectal Surgery Critical Care Medicine Dermatology Emergency Medicine Endocrinology Family Practice Gastroenterology General Practice General Surgery Geriatric Medicine Gynecologic Oncology Gynecology Hand Surgery Hematology Infectious Disease Internal Medicine Medical Genetics Nephrology Neurological Surgery Neurology Nuclear Medicine Obstetrics Obstetrics / Gynecology Oncology Ophthalmology Orthopaedic Surgery Otolaryngology Pain Management Pediatric Cardiology Pediatrics Pediatric Endocrinology Pediatric Surgery Pediatrics Physical Medicine / Rehab Plastic Surgery Preventive Medicine Psychiatry Pulmonary Disease Radiology Reproductive Endocrinology Rheumatology Sports Medicine Thoracic Surgery Urology Vascular Surgery Other Primary Care Physician: Phone number(s): Daytime Evening Emergency Email: Website address: Street address: City: State: Choose a state Alabama Alaska Arizona Arkansas Outside USA 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 Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip or postal code: Country: Comments: (maximum 150 words)