Voice Expert Healthcare Referral List Submission Form If you are a healthcare professional that treats people with voice disorders like spasmodic dysphonia, please submit your contact information below to be considered for the on-line NSDA Voice Expert Healthcare Referral List. This submission is a:This form can be used to both submit a new listing or update your contact information. This is a new listingPlease update my informationNotes (not to be listing on the directory)Contact InformationPlease note we can only list one address. If you practice at multiple sites, please list the main one below and you can include the address of other sites in the box below the address. PrefixName* First Last SuffixAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Practice Name/Institution (required)DepartmentTitleOffice Phone (for patients for to call)*Office Fax (if applicable)Email* Please note: E-mail addresses are not listed on the website, for internal use only)Website Other Locations:About Your PracticeMedical SpecialtyPlease check one: Laryngologist Otolaryngologist Speech-Language Pathologist Movement Disorder Specialist Other Medical Speciality:Treatment OptionsBotulinum Toxin InjectionsCheck all that apply Adductor Spasmodic Dysphonia Abductor Spasmodic Dysphonia How many Botox injections do you perform monthly? (if applicable)Please enter a number from 0 to 200.Surgical TechniquesCheck all that apply Selective Laryngeal Adductor Denervation-Reinnervation (SLAD-R) Thyroplasty II Thyroplasty I Other Surgical Techniques:Rehabilitation ServicesCheck all that apply Speech Therapy Myofascial Release Laryngeal Massage Other Rehabilitation Services:Additional Treatment OptionsCommentsConsent* I agree to be added to the NSDA Voice Expert Healthcare Referral ListBy submitting this form, I agree to have my contact information to be listed on the NSDA website (www.dysphonia.org) and be added to the NSDA mail and e-mail distribution list. CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.
