Form

Shields Express Link - Physician Registration

First name*

Last name*

Email*

Clinician*

Clinical (MD, PA, NP, etc.)

Medical Assistant

Non-clinical (administrative, support, etc.)

NPI Number*

Specialty Category*

Name of physician(s) who refers:*

Office/Practice Name*

Office Phone Number*

Fax number*

Street Address*

City*

State/Region*

Zip Code*

Doctors in Practice:

Do you need appointment confirmation?*

Yes

Would you like your report faxed or will you view it on SEL?*

FAX

SEL

Sign me up for access to reports & images via Shields Express Link. Please have a sales rep contact me

Select your Regional Marketing Representative. If you do not know, please leave blank.