International facility membership Honorary Invalid form configuration. Invalid "custom" attribute. When provided, must start with your domain name. Registration Options Honorary Membership Create Profile First Name * Last Name * Email Address * Username (lowercase alphanumeric) * Password (type this twice please) * password strength indicator Additional Info Salutation (Dr, Miss, Mrs, Mr, Professor, etc.) * Contact Details Professional Initials Title/Position Are you a Director, Administrator or Manager? No Yes Professional Specialty * OtherRN RT StudentFellowRegistered NurseNurse NavigatorRadiologic TechnologistTechnologist NavigatorOther NavigatorGenetic CounselorNurse PractitionerPhysician AssistantDoctor of MedicineDoctor of OsteopathicBreast SurgeonMedical OncologistPathologistPlastic SurgeonRadiologistRadiation Oncologist Published to directories for the public Department Facility Name * Facility Street Location Address * Facility Mailing Address if different from Street Address City * State * Zip * Country * Preferred Mailing AddressAdd Facility/Department field if not a home address Address Street * Address City * Address State * Address Zip * Address Country * Business Numbers for General Public/Clients. Published to facility and vendor directories for the public General Public # * General Public Email Fax Website Direct Numbers of Applicant Preferred Tel # * Alternate Tel# Email Identify area(s) about which you would be willing to share your expertise (Hold control key down to select more than one) -- Select Here --Policy and Procedures ManualStaff Roles and Job DescriptionsAdministrative SoftwareTracking SoftwareBreast Center Physical SettingsStarting a Breast CenterExpanding a Breast Center to a Women's CenterMarketing TechniquesMachinery and EquipmentPurchase/FeasibilityMerging Facilities/Buyouts - Patient ImpactMerging Facilities/Buyouts - AdMinistrative/Operation ImpactClinical Pathway DevelopmentMobile MammographyPatient Educational ResourcesLymphedema ProgramsHigh Risk ProgramsOutreach ProgramsClinical TrialsBreast ReconstructionBreast AugmentationNutritional Counseling/InformationPsycho-social services/programs Patient Services - This information will appear on your Internet Listing Mobile Mammography (Hold control key down to select more than one) -- Select Here --ProvidedNot provided Number of units (sites) Self-Referrals Accepted (Hold control key down to select more than one) -- Select Here --YesNo Diagnostics (Hold control key down to select more than one) -- Select Here --Fine needle (FNA)Core biopsyUltrasoundStereotacticGalactographyScintimammographyOsteoporosis testingMRI Guided Needle Biopsy Rehabilitation (Hold control key down to select more than one) -- Select Here --Lymphedema programPhysical TherapyProsthesis Fitting Other services for women offered on site (Hold control key down to select more than one) -- Select Here --Coordination of pre-natal servicesCoordination of ob/gyn servicesCoordination of osteoporosis servicesCoordination of preventative servicesParticipate in clinical trials Interdisciplinary Breast Team (Hold control key down to select more than one) -- Select Here --Hold Multidisciplinary Breast ConferenceHolds Weekly Prospective Breast ConferenceHas Certified Breast Patient Navigator On SiteHas Certified Clinical Breast Examiner On Site Certifications/Accreditations (Hold control key down to select more than one) -- Select Here --NQMBCNAPBCBICOE Treatment (Hold control key down to select more than one) -- Select Here --ChemotherapyRadiation therapy Patient Education (Hold control key down to select more than one) -- Select Here --High Risk counselingPatient Resource literaturePatient Resource library/dedicated areaComplementary and Alternative medicineLife StylesNutrition counselingPsychosocial counselingPatient educator on staffPatient Advocacy and Survivorship GroupsCoordinate Social Service options for patients Surgical (Hold control key down to select more than one) -- Select Here --Reconstructive surgeryCosmetic SurgerySentinel Lymph node mapping and biopsyDuctal Lavage for high risk women Business Description Please provide a description of your business. (I.e., services/products offered) The description you provide will be included on your Internet listing. You may attach or e-mail copy if more space is needed. Membership Networking Would you be willing to prepare an article or be interviewed and have our writer prepare an article about your breast center or its programs to be included in a future copy of the NCBC newsletter, the Breast Center Bulletin ? (Hold control key down to select more than one) * -- Select Here --YesNo From time to time we offer informational product information that we share and a bi-weekly Newsletter for our members. If you prefer not to receive these email, please un-check this box From time to time we offer informational product information that we share and a bi-weekly Newsletter for our members. If you prefer not to receive these email, please un-check this box Complete Registration Submit Form
