Apply to Surgeon Locator Directory

Please provide the following information as you wish it to appear in your listing on the website.

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Lng - Administrative

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Lat - Administrative

Full name*

Title*

Address

Primary practice name*

Primary office address*

City*

State*

Zip*

Office phone*

Office website*

Additional practice location

I have a second office

Second office address

Street address*

City*

State*

Zip*

Office phone*

Affiliated hospitals

Name(s)

Specialties

(check all that apply)

Anatomical areas of specialty

Facial/neck

(check all that apply)

Breast

Breast

Upper extremity

(check all that apply)

Groin

(check all that apply)

Urological (i.e., prostate)
Pelvis

Lower extremity

(check all that apply)

Conditions treated

(check all that apply)

Practice key contact

This tool helps patients contact your practice. Please make sure the contact information you provide can appropriately receive personally identifiable information in accordance with applicable privacy requirements (for example, HIPAA, as applicable). This person should be knowledgeable about your listing on the surgeon locator. Do not submit any patient information through this form.

Key contact first name*

Key contact last name*

Key contact phone*

Key contact email*

Axogen does not recommend or endorse any physician and does not provide medical advice.

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 for my practice in its surgeon locator tool as part of its effort to connect patients to physicians who treat peripheral nerve injuries.
I represent that I am authorized to submit this information and to permit Axogen to use it as described.
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 upon request.
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 surgeon locator tool; (ii) any use or misuse of the information provided hereafter; or (iii) the decision by Axogen to discontinue the surgeon 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 Axogen Customer Care at CustomerCare@AxogenInc.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 Axogen reserves the right to exclude my information in the online surgeon locator tool program.
I confirm that my institution allows my name to be used for the purposes described above.

NPI Number*

NPI Number will be used for verification purposes only. It will not be published on Axogen’s Find a Nerve Surgeon website page.

Surgeon locator application

Please provide the following information as you wish it to appear in your listing on the website.

Address

Additional practice location

Second office address

Affiliated hospitals

Specialties

Anatomical areas of specialty

Conditions treated

Practice key contact

Connect with an Axogen rep if you have questions about the form or need more information.