Physician Locator Registration

I hereby request Urologix to add my contact information to the Urologix Physician Locator web page:

Name*
First Last
Clinic
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Fax
Email
Treatment*
- Cooled ThermoTherapy
- Prostiva RF Therapy
Would you like Urologix to include a link to your website?*
- Yes
- No
Website
Please feel free to include the Urologix website on your website using the link http://urologix.wpengine.com/
Name of Person Authorizing*
Date*
Month
Day
Year
*
- By checking this box, I confirm the physician listed is trained and experienced in the treatment(s) noted.
Please note: The Urologix Physician Locator lists physicians who have been trained in, and experience providing Cooled ThermoTherapy™ or Prostiva RF Therapy to treat benign prostatic hyperplasia (BPH). Urologix provides this listing on its website as a service to potential patients. Urologix does not provide any representation, assurance or guarantee with respect to services provided by Physicians listed on the Urologix Physician Locator. The Urologix Physician Locator may not include all physicians who have been trained in, and have experience providing, Cooled ThermoTherapy™ or Prostiva RF Therapy to treat BPH.