surgeon submission form

first name*

middle name

last name*

title

MD
FACS
DPM
MBChB

specialty (mark all that apply)

anatomical areas of specialty

Your profile will only be shown to potential patients whose anatomical areas of concern align with the areas you are open to treating.

facial/neck (check all that apply)

Neck
Mouth/jaw
Face
Tongue
Migraine

torso

Breast (post-mastectomy pain)
Chest
Laparoscopic nerve injuries
Groin
Hernia pain

upper extremity (check all that apply)

Finger
Forearm
Brachial plexus
Hand
Elbow
Shoulder

lower extremity (check all that apply)

Buttock
Knee
Foot
Ankle
Sciatic
Lower leg
Upper leg

primary hospital or surgery center information

primary hospital or surgery center*

website*

office phone*

Hidden

secure email account

practice logo

Accepted file types: jpg, gif, png, Max. file size: 50 MB.

practice key contact

We’re excited to connect you with potential surgical candidates. Please make sure the contact information you provide can appropriately receive personally identifiable information per HIPAA protocols. This person should be knowledgeable about your listing on the Rethink Pain surgeon locator.

key contact first name*

key contact last name*

key contact phone*

key contact email address*

address

street address suite city (city only) state zip code

additional primary hospital or surgery center

I have a second office

second primary hospital or surgery center

second office phone

Hidden

second office contact email

second office website

second practice logo

Accepted file types: jpg, gif, png, Max. file size: 50 MB.

second address

street address suite city (city only) state zip code

practice key contact

second office key contact first name

second office key contact last name

second office key contact phone

second office key contact email address

affiliated hospitals

name(s)

education, certifications and awards

undergrad

format example "B.S. from Stanford University in California"

medical degree

format example "University of Texas Southwestern Medical School in Dallas"

residency

format example "Plastic surgery at Baylor College of Medicine in Houston"

certifications

awards

image upload

headshot

Max. file size: 50 MB.

Axogen also has a surgeon locator on axogeninc.com. Would you also like your profile listed on the locator on Axogeninc.com?

yes
no

By submitting your request, you are indicating that you agree to the following:

I hereby do grant Axogen permission to use contact information for me and my practice in its physician locator tool as part of its effort to connect patients to physicians who treat peripheral nerve injuries.
I understand and agree that the information submitted and indicated for inclusion in the locator tool may be made publicly available on one or more Axogen websites within the search function or may be provided to a patient by an Axogen associate.
I understand and agree that the contact information for my name and for my practice may be made publicly available in one or more specialty-specific physician locator search tools that Axogen may develop for its website(s) depending on my medical specialty(ies).
I understand and agree that Axogen will seek to make sure all information is accurate, however Axogen will bear no responsibility or liability for (i) inaccurate, incorrect, incomplete, or outdated information provided to patients through the physician locator tool; (ii) any use or misuse of the information provided hereafter; or (iii) the decision by Axogen to discontinue the physician locator tool at any time and without notice to participant.
I understand and agree that I may update my contact and practice information, or otherwise modify the permission granted at any time by sending written notice to info@rethinkpain.com
I understand and agree that the information I submit to be included in the locator tool will be governed by Axogen’s privacy policy for its website(s).
I understand and agree that I may receive and use certain content, marketing materials, downloadable assets and intellectual property of Axogen (collectively, “Axogen IP”) to educate, market and promote Rethink Pain ™and such use will be governed by Axogen’s Terms and Conditions
I understand and agree that Axogen reserves the right to exclude my information in the online physician locator tool program.
I confirm that my institution allows my name to be used for the purposes described above.
I have no disclosures regarding allegations/convictions of crimes against me, open malpractice liability claims or changes in the status of my medical licensure.
NPI number*

*NPI Number will be used for verification purposes only. It will not be published as part of the physician locator tool program.