Healthcare Professionals Directory Registration Form - The Ehlers Danlos Society : The Ehlers Danlos Society

The Ehlers-Danlos Society provides an online directory of EDS/HSD-friendly health professions.

Inclusion in the directory does not constitute an endorsement by The Ehlers-Danlos Society, but is provided as a service to the EDS/HSD community—and to healthcare professionals interested in treating those living with EDS, HSD, and related disorders.

By submitting this form, health professionals certify they are licensed to treat patients; familiar with EDS, HSD, and related disorders; and willing to treat patients who may be living with such conditions.

If you would like to be included in the list, please fill out the form below.

Name*

First Last

Professional Designation(s)*

I.e. MD, PT, DDS

Are you a member of The International Consortium on EDS, HSD, & Related Disorders?*

Yes
No

Are you EDS ECHO alumni?

Yes
No

To apply to become a member of The International Consortium on The Ehlers-Danlos Syndromes & Related Disorders, click here.
Note: This link opens to a new window so that you do not lose your place on this form.

How many clinics do you have?

1
2
3
4

Practice/Clinic Group Name*

Practice/Clinic Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice/Clinic Phone*

This number is for Ehlers-Danlos Society use only.

Practice/Clinic Website

Practice/Clinic Group 2 Name*

Practice/Clinic 2 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice/Clinic 2 Phone*

This number is for Ehlers-Danlos Society use only.

Practice/Clinic 2 Website

Practice/Clinic Group 3 Name*

Practice/Clinic 3 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice/Clinic 3 Phone*

This number is for Ehlers-Danlos Society use only.

Practice/Clinic 3 Website

Practice/Clinic Group 4 Name*

Practice/Clinic 4 Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Practice/Clinic 4 Phone*

This number is for Ehlers-Danlos Society use only.

Practice/Clinic 4 Website

UK medical professionals ONLY. Is your clinic...

NHS
Private
Both NHS and Private

Email*

This address is for Ehlers-Danlos Society use only.

Email for Patient Use*

This address is for patients to use to contact you.

Phone for Patient Use*

This number is for patients to contact you.

Medical Specialties*

Please separate by commas.

Do you have hospital affiliations?*

Yes
No

Hospital Affiliation 1

Hospital Affiliation 2

Hospital Affiliation 3

Tell us about your practice/clinic*

limit to 1,200 characters

Professional Background

Do you have professional board affiliations?*

Yes
No

Professional Boards and Affiliations 1

Professional Boards and Affiliations 2

Professional Boards and Affiliations 3