This submission is to be used ONLY for the submission of specific physician or physical therapist names for our database. It is NOT to be used by patients seeking physician information.

Patient Recommendation Form

Thank you for taking the time to share your medical care provider names with us. Finding a compassionate doctor who treats interstitial cystitis can be challenging at best. Whether it's a small town clinic with one physician or a major university health department, every name is important because it may help another patient, after you, who is also struggling to find care.

We're looking for medical professionals who treat IC patients with compassion and professionalism. You, the IC patient, are the front line of our movement. You've had the chance to talk with several medical professionals, work with support staff, experience various tests and try various treatments. Who treated you well?? Who listened? Who responded to your phone calls when you were frightened or in a flare?

We'd like your recommendations for md's (urologists, obgyns, etc.), physical therapists, pain specialists, dietitians, counselors, sex therapists and/or educators. We're also looking for providers who specialize in age groups, such as pediatric urologists who work with children who have IC.

What will we do with your recommendation? We'll send a letter to the physician letting them know that they've been recommended by one of their patients as an outstanding resource for IC patients and ask if they would like to be included in our list. We will NOT disclose your name in that letter to maintain your privacy. We will also send them more information on IC!

Thank you for helping us! - Jill Osborne, ICN Founder

Medical Provider Submission Form (Please submit as much information as you can)
Provider First Name
Provider Last Name
Provider Credentials	MD DO PT RN Other
Provider Specialty	Urologist Urogynecologist OB/GYN Family Practitioner Nurse Practioner Pain Specialist Dietitian Therapist/Counselor Educator Other
Organization or Clinic Name
Address
City
State
Zip Code
Country
Office Phone Number
Fax Number
Clinic E-mail Address
Your Name & Email Address (not required but really helpful if we have any questions and would like to get back to you.)
Why do you like this provider? What was your care like? What would you like to tell other patients about this provider?