Form for Allergists

Notice

Please complete the form on this page in order to have your OIT practice listed on the FAST website. Mandatory fields are indicated with an asterisk.

You must list a board-certified allergist as the primary OIT physician. If you would like to post the names of other physicians or advanced practice providers (PAs, NPs), you may do so in the “Additional OIT providers” field. If you wish to have multiple practice locations as separate listings, these will require separate fees. However, keep in mind that your practice URL will be listed. This may be a more efficient way for patients to view practices with multiple locations.

Listing will be paid for 1 year.

TO RENEW LISTING: You will receive an auto-renewal email when it’s time to renew. If you have any questions or need to update your email address please fill out the form at https://fastoit.org/contact-us/ .

Practice Info

Practice Name *

Practice location - Street, City, State, Zip Code *

Primary Board Certified Allergist *

Additional OIT Providers at Location

Web link (e.g., www.fastoit.org) *

Name your top social platforms for interacting with patients or potential patients instagram, facebook, etc.).

Billing First Name

Billing Last Name

Billing Address

City

State/Province

Zip/Postal

Listings are $250/year. Submitting this form will create a recurring annual subscription.

Credit Card

If you are human, leave this field blank.