National Vulvodynia Association

www.NVA.org

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Healthcare Professional:

$75

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Mailing Information: Same as billing?

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First Name:
Last Name:
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Country Code:
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CC #:	We Accept Visa / Mastercard
CID / CVV:	(The last 3-4 digits on the back of your card)
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Tell us more about yourself:

I have the following degrees:	I specialize in the following type of medicine:
MD PhD DO RN PA NP PT / OT MS MPH MSW Other:	Anesthesiology Dermatology Family Medicine Gynecology Neurology Obstetrics Pain Medicine Psychiatry Psychology Physical Therapy Sex Therapy Urology Urogynecology

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I would like to be listed in NVA's healthcare provider database

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Do you provide obstetrical care?

Are you conducting clinical or basic science research to vulvodynia?

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Average number of vulvodynia patients seen per month:

Percentage of your practice that is devoted to either:

Vulvar disorders	%
Chronic Pain	%

Professional organizations to which you currently belong:

The National Vulvodynia Association (NVA) is an educational, nonprofit organization founded to disseminate information on vulvodynia. The NVA recommends that you consult your own health care practitioner to determine which course of treatment or medication is appropriate for you.

Last updated March 7th, 2007