Join now by entering your information as a new physician. State: InternationalAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingD.C.AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon TerritoryPuerto Rico First Name: Last Name: Practice Name: Address: City: Country:* Zip or Postal Code: Fax: (xxx)xxx-xxxx Work Phone:(xxx)xxx-xxxx E-Mail: Web Site Address: http:// Notes (One or two sentences only): Administer Botulinum Toxin Injections for: Spasmodic Dysphonia Other Forms of Dystonia Forms of Dystonia Treated: Spasmodic Dysphonia Other Forms of Dystonia Medical Specialty: Family Practitioner Movement Disorders Specialist Neurologist Neurosurgeon Nurse Practitioner Otolaryngologist (ENT) Speech-Language Pathologist-Therapist Treatments: Selective Laryngeal Adductor Denervation Speech Therapy Thyroplasty Other: Do you treat children? No Yes Would you like to receive our Healthcare Literature Kit, which contains educational literature on Spasmodic Dysphonia for you to distribute to your patients? No Yes Lastly, to ensure that this form is being submitted by a real human being (we get a lot of spam through this form), please identify the subject of the photo below by selecting the corresponding word from the drop-down menu: Pictured at right is: Drums Earth Eggs Fireworks Flower Puppy Stream