Your Name (required)
Your Email – please use your AARA email (required)
Do you want your AARA email displayed on your landing page? YesNo
Practice Name (required)
Practice Address 1 (required)
Practice Phone 1 (required)
Practice Fax 1 (required)
Practice Address 2
Practice Phone 2
Practice Fax 2
Practice Description (for left column – required) Please provide a full paragraph in sentences.
Practice Highlights – What does your Practice offer / specialize in (for right column)
URL to your Practice Website (if available)
If you would like the logo of your Practice displayed, please attach here
Physician Name 1 (required)
Board Certified in: Internal MedicineRheumatology
Physician Description 1 (education, hobbies)(required) Please provide a full paragraph in sentences.
Physician Name 2
Physician Description 2. Please provide a full paragraph in sentences.
Nurse Practitioner Name 1
Nurse Practitioner Description 1. Please provide a full paragraph in sentences.
Nurse Practitioner Name 2
Nurse Practitioner Description 2. Please provide a full paragraph in sentences.
Insurance Plans Accepted
URL to your Patient Forms if available online (preferred)
Practice Forms, if in PDF format
Practice Forms 2
Please attach a high resolution headshot, unless you had one taken at the AARA/Bendcare office
