Registration Membership Information You have selected the Clinics membership level. The 1st year clause: Registering for the ALPS Clinic Directory is free for the first year. Your listing will not automatically convert to a paid subscription without prior notification and the opportunity for you to choose how you would like to proceed. Important: Please use your clinic’s general email (e.g. info@clinic.com). Individual emails may create duplicate memberships. The price for membership is $0.00 now. Do you have a discount code? Click here to enter your discount code Discount Code Account Information Username Password Show Password Confirm Password Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in here Clinic Website Clinic Name Website About Clinic Please provide a short description of your clinic. Affiliations Hospital Medical School Care Setting Hospital Based Select your option Yes No Outpatient Based Select your option Yes No Multispecialty Select your option Yes No Which Specialities Does your program provide patient/family support or education meetings? Select your option Yes No Accepted Insurance Plans Clinical Staffing Director Name Board Certifications Years in Limb Preservation Time dedicated to Limb Preservation Name Credentials Clinic Doctors Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Clinic Nurses Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Full Name Credentials Board Certifications Specialty Cardiologist Clinical scientist Diabetes educator Dietitian/Nutririonist Endocrinologist Engineer/Scientist Infectious disease specialist Interventional radiologist Nurse Nurse practitioner Orthopedic surgeon Other Pedorthist Physical therapist Plastic surgeon Podiatrist Primary care Public health/Epidemiology Student Vascular surgeon Training & Research Limb Preservation Training for Fellows? Select your option Yes No Programs that Apply Does the clinic provide pre-doctoral training? Select your option Yes No Does the clinic provide residency training? Select your option Yes No Does the clinic provide fellowship training? Select your option Yes No Does your program undertake limb preservation research? Select your option Yes No Directors Description Description Please add any additional information (e.g., satellite programs) of your program. 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American Limb Preservation Society Billing Address First Name Last Name Address 1 Address 2 City State Postal Code Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands US Armed Forces Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Phone Payment Information Card Number Expiration Date CVC Discount Code Processing...
