Medical Clinic Registration (Affiliated)

Congratulations!  You are on your way to becoming the newest member of NIFLA.  Please take a moment to fill out our registration form below.  Afterwards, you will be directed to check out of our online store with a new membership.

Please be aware that your membership application is not complete until you have filled out the form and paid through our online store.  Once paid, our home office staff will be in touch with you

    Center Name*:
    Physical Address*:
    City, State, Zip*:
    Mailing Address*:
    City, State, Zip*:
    Director's Name*:
    Director's Email*:
    Website:
    Phone Number*:
    Fax Number:
    Board Chair*:
    Medical Director*:
    Nurse Manager*:
    Nurse Manager Email*:
    Attorney:
    Attorney Email:
    Other Affiliations: Life Matters WorldwideCare NetHeartbeat InternationalInternational Life Services

    Only press continue AFTER sending the form above.

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