Physician Survey Form

We offer this Directory as a resource to women and couples who seek physicians practicing medicine in accord with traditional Christian principles. The physicians listed in this directory do not prescribe, perform, or refer for contraception, sterilization, abortion, or in vitro fertilization.

In order to be able to confidently refer individuals or couples to physicians who subscribe to these values, we ask physicians to complete this online survey detailing their stance on issues of contraception, sterilization and abortion. Those physicians who qualify, and who gave us permission to use their names are included in this Directory.

1. About Yourself

1. What kind of entry is this?I'm submitting a new entryPlease update an existing entryPlease remove my entry from your list
2. Name
3. Suffix
4. Specialty
5. General CategoryFamily Practice/Internal MedicineFamily Practice with OBOb-GynUrologyPediatrics/Neonatology
6. Office Name
7. Type of Practice

2. Contact Information

1. Address
2. Address 2
3. City
4. State-- Please select a state --ALABAMA (AL)ALASKA (AK)AMERICAN SAMOA (AS)ARIZONA (AZ)ARKANSAS (AR)CALIFORNIA (CA)COLORADO (CO)CONNECTICUT (CT)DELAWARE (DE)DISTRICT OF COLUMBIA (DC)FEDERATED STATES OF MICRONESIA (FM)FLORIDA (FL)GEORGIA (GA)GUAM (GU)HAWAII (HI)IDAHO (ID)ILLINOIS (IL)INDIANA (IN)IOWA (IA)KANSAS (KS)KENTUCKY (KY)LOUISIANA (LA)MAINE (ME)MARSHALL ISLANDS (MH)MARYLAND (MD)MASSACHUSETTS (MA)MICHIGAN (MI)MINNESOTA (MN)MISSISSIPPI (MS)MISSOURI (MO)MONTANA (MT)NEBRASKA (NE)NEVADA (NV)NEW HAMPSHIRE (NH)NEW JERSEY (NJ)NEW MEXICO (NM)NEW YORK (NY)NORTH CAROLINA (NC)NORTH DAKOTA (ND)NORTHERN MARIANA ISLANDS (MP)OHIO (OH)OKLAHOMA (OK)OREGON (OR)PALAU (PW)PENNSYLVANIA (PA)PUERTO RICO (PR)RHODE ISLAND (RI)SOUTH CAROLINA (SC)SOUTH DAKOTA (SD)TENNESSEE (TN)TEXAS (TX)UTAH (UT)VERMONT (VT)VIRGIN ISLANDS (VI)VIRGINIA (VA)WASHINGTON (WA)WEST VIRGINIA (WV)WISCONSIN (WI)WYOMING (WY)-----------------------------------Armed Forces Africa (AE)Armed Forces Americas (AA) (except Canada)Armed Forces Canada (AE)Armed Forces Europe (AE)Armed Forces Middle East (AE)Armed Forces Pacific (AP)
5. Zip
6. Email
7. Website
8. Office Phone
9. Office Fax

3. Survey

1. I do not and will not prescribe or refer for hormonal contraception
2. TrueFalse
3. I do not and will not prescribe or refer for barrier forms of contraception
4. TrueFalse
5. I do not and will not perform or refer for abortion
6. TrueFalse
7. I do not and will not perform or refer for sterilization
8. TrueFalse
9. I do not and will not perform or refer for in-vitro fertilization
10. TrueFalse
11. I am familiar with Natural Family Planning
12. TrueFalse
13. I do promote abstinance for my young and/or unmarried patients
14. TrueFalse
15. I will promote breastfeeding for healty moms and babies
16. TrueFalse
17. I am qualified and willing to perform sterilization reversals for men
18. TrueFalse
19. I am qualified and willing to perform sterilization reversals for women
20. TrueFalse
21. (If applicable) I am willing to reduce my fee for sterilization reversals as a ministry to those who desire to follow God's Will in this area
22. TrueFalseN/A
23. Comments

4. Questions for NFP-Only Medical Professionals

1. I am certified as an NFP instructor by
2. Model
3. I have been trained as an NFP/NPT* medical consultant by
4. I have used NFP/NPT* based medical procedures to treat patients for infertility and other reproductive system disorders.
5. TrueFalseN/A
6. I have conducted or currently conduct medical research on the development and application of NFP/NPT*
7. TrueFalseN/A

5. Agreement

1. I confirm that all the above information is correct and give One More Soul permission to publish this information in their NFP-Only Medical Professionals Directory and at their website (http://onemoresoul.com)
2. I agree
3. Please enter the characters from the CAPTCHA window: