Contact

Contact an IPCGD Admin

Register Interest

IPCGD is still forming a core interest group of local practices.

Fill out this form to register your interest in participating as an independent provider or practice.

Practice Name *
Area(s) of Practice / Specialties *
Contact Name *
# of Providers *
Contact Phone (Optional)
Contact Email Address *
More information (location, website, etc.)
Is this practice independent? *

Registered interest does not guarantee participation.

-OR-

Report an Issue

If you find something is broken, misrepresented or perhaps represented but you would rather it be excluded – let us know!

What are you reporting? *
How can we reach you? *
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