HCP Signup Form
Please use this form to signup for our HCP email list. All submissions will be verified against the NPI registry. Don't have an NPI number? Please use the general contact form at chicago-ms.org. *Note: any submissions by HCPs employed by pharmaceutical or biotech companies will be denied.*
First Name
*
Please use legal name as registered with the NPI registry
Last Name
*
Please use legal name as registered with the NPI registry
Email
*
Preferred contact email for the email list
NPI Number
*
For verification purposes
Professional Role
*
Please Select
Physician
NP/PA, Nurses
Allied Health Professional
Other
This is for email sub-lists. Everyone will be on the main list.
Submit
Should be Empty: