MAOI Friendly Doctors Form -

What is your Email address?*

Please note, this will not be displayed on the database. It is only for site admins to contact you if there is an error with your entry or something is unclear.

Are you a patient or a Doctor?*

Patient
Doctor

Note: Unless you are a doctor or psychiatrist, please select "patient".

Doctor Name*

First Last

Name of Clinic

Address*

Street Address Suburb City State / Province / Region ZIP / Postal Code Country

Type of Doctor*

General Practitioner / Family Doctor
Psychiatrist

Phone*

Email

Website

Were you already on MAOI?*

Yes
No

Were you already on this MAOI when you saw this doctor? Yes for getting more or No for getting MAOI for the first time.

Prescribed MAOI (Nardil or Parnate) ?*

Yes
No

Notes

Are you willing to prescribe MAOIs?*

Yes, to patients not already on one
Yes, to patients already on one

Such as Nardil or Parnate?

Name

This field is for validation purposes and should be left unchanged.

MAOI Friendly Doctors Form

Doctors who did or didn't prescribe a MAOI