Want To Join Our Network?

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*	Physician/Ancillary Name:
*	Address:
*	City, Zip:
*	Phone:
*	Contact Person Name:
*	Contact Person Email:
*	Specialty:
	Any special details regarding your Specialty:
	Has a TeamChoice member requested that you contact us?
	Do you currently have TeamChoice patients?
	Comments:

Note: Due to confidentiality issues a TeamChoice representative will contact you to see how TeamChoice can help you with your healthcare needs.

TeamChoice

309 North Slide Road
Lubbock, TX 79416
806-795-5959 (main number)
800-683-3596 (toll free)
806-722-2403 (fax)