AI Physician Recommendations

AI Physician Recommendations

This is for Endos or other physicians who treat adrenal insufficiency with the use of steroid medications. Please fill out as completely as possible the information about the physician you would like to recommend.
Name of Physician

First NameLast Name
If you are recommending more than one physician from the SAME practice please add their names here. If you'd like to recommend someone from a different practice please fill out a new form.

Even if you LOVE your physcian please DO NOT purposely recommend them more than one time.
Practice/Hospital etc.

Name of Practice or if individual doctor just say NA

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Scheduling Dept Phone

Area CodePhone Number
Does this physician or practice treat?
Type of physician: Endo, Functional Med, Primary Care etc.
What qualities make this physician or practice great?
Your E-mail in case we have a question about the referral.
Does this physician use steroids to treat AI.
Does this physician support use of the Pump to treat AI.
Is this an edit for a record on our map.
Should be Empty: