Surgeon locator physician application

Hidden

Lng - Administrative

Hidden

Lat - Administrative

Full Name

title*

primary hospital or surgery center information

Primary Hospital or Surgery Center*

website

office phone

office contact email

Address

office address

City

State

Zip

specialties

specialty (mark all that apply)

Anatomical Areas of Specialty

Facial/Neck (check all that apply)

breast

breast reconstruction with Resensation® technique

Upper Extremity (check all that apply)

Lower Extremity (check all that apply)

conditions treated

Numbness/Loss of sensation (check all that apply)

Muscle weakness (check all that apply)

hand and arm
foot and leg
head, neck & face
other

Other conditions (check all that apply)

I use Axogen’s nerve repair products?

yes
no

I have attended an Axogen course or symposium?

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 for 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is accurate, however Axogen will bear no responsibility or liability for (i) inaccurate, incorrect, incomplete, or outdated information provided to patients through the physician locator tool; (ii) any use or misuse of the information provided hereafter; or (iii) the decision by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 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 physician locator tool program.
I confirm that my institution allows my name to be used for the purposes described above.

After submitting this form, an Axogen Customer Care representative will contact you to confirm submission and approval prior to publishing your information.

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

primary hospital or surgery center information

Address

specialties

Anatomical Areas of Specialty

conditions treated