Paid Doctor Registration - BlackDoctor.org - Where Wellness & Culture Connect

Approximately, what is the percentage of minority patients seen in this practice annually? For health companies, select the percentage you service.*

Practice/Business Address*

Street Address Address Line 2 City State ZIP Code

Other Location Address

Street Address Address Line 2 City State ZIP Code

Practice/Business Website

Are you an owner/partner of the practice(s)/business listed above?

What type of practice do you work?

Other

Does your practice offer...*

List your Medical Association memberships

Do you have a desire to increase/improve the access to care to minority patients in your practice/business? If so, give a brief statement as to why.

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