Physician Registry

NOTE: This form should be used to request physician registry listings for physicians inside of the United States. If you would like to request a registry for physicians outside of the US, please click here.

The ICA has an extensive listing of physicians in the United States who treat IC. If you are interested in receiving the list for your state via e-mail, please fill out the form below, providing all information requested. We will be pleased to e-mail you a list of up to three states of your choice (allow 2-3 business days).

In order to participate in the ICA Physician Registry, the ICA asks that physicians be knowledgeable in current IC diagnostic and treatment options and be interested in caring for persons with IC. Their listing here is neither a recommendation nor an endorsement by the ICA. The physician registry is not a complete list of all physicians in your area, nor does it guarantee standard of care. We encourage patients to educate themselves about IC and become a partner in their medical care.

First Name*
Last Name*
Date of Birth*
Gender*	FemaleMale
Are you a current member of the ICA?*	YesNo
Have you been diagnosed with IC?*	YesNo
E-mail Address*
Home Phone*
Work Phone
Address 1*
Address 2
Address 3
City*
State/Province*
Zip/Postal Code*
I would like to request a listing of physicians in the following (US) state(s) [you may choose up to three]:

First Choice*
Second Choice
Third Choice


* Required