Registration for Practitioners

Practitioner Registration

Name

Email Address

Phone Number

State ACTNSWQLDSANTWAVICTAS

Postcode

Are you a:

General Practitioner

Medical Specialist

Complementary Medicine Practitioner

What is your speciality or area of particular interest?

Website/URL

Do you see patients presenting with problems associated with reactions to "everyday items"? These things include perfume, freshly printed papers, new carpet, or electromagnetic radiation.

Yes

No

Do you feel that improved clinical guidelines and diagnostic tools and more resources are needed?

Yes

No

Comments

Can we publish and/or share your name and medical practice details? *

Yes

No

Please upload your clinic logo, if you would like your details shared.

Drop a file here or click to upload Choose File

Maximum file size: 2.1MB

Please indicate if you feel that your clinic is safe for the following people:

chemically sensitive

electrically sensitive

wi-fi free

OtherOther

fragrance-free

Is there some way that you could support us in achieving our goals? If so, how?

Δ

Please show your support for this project by registering yourself and/or your practice and providing some basic information on the numbers of people you see with ES. Please share the information about ANRES with your patients and colleagues and encourage them to register. Your presence on the ANRES site may assist individuals in finding the right practitioner for them.