PCP Registration Form
Before utilizing NV PAL, primary care providers are required to register for our services using this form. Registration only takes a minute!
PCP name:
*
First Name
Last Name
Name of clinic, if applicable:
Provider type:
*
Examples: MD/DO, APRN, Physician’s assistant
Provider specialty:
*
Pediatrics
Family medicine
Other
Direct email address:
*
Example: jsmith@clinic.org
Best phone number:
*
*For physician-to-physician contact; CELL NUMBER preferred!
Nevada county where located:
*
Carson City
Churchill
Clark
Douglas
Elko
Esmeralda
Eureka
Humboldt
Lander
Lincoln
Lyon
Mineral
Nye
Pershing
Storey
Washoe
White Pine
Each month, we send 1-2 important emails about Nevada-specific mental health issues and NV PAL program updates. May we include you in those emails?
*
Yes
No
Submit
Should be Empty: