Orange County Vital Brain Program

Participate

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Enroll in the Vital Brain Program

The most direct form of involvement with the Orange County Vital Brain program is to become a "Participating Physician" by formally enrolling. Enrolled physicians will be listed in the Vital Brain publicly searchable database of care providers who adhere to high standards for managing cognitive health. The participating physicians may also draw on free, Vital Brain educational materials for their patients.

Before completing and submitting the following form, we encourage you to take a moment to review the program's clinical guidelines, "Managing Cognitive Vitality in a Primary Care Setting." These guidelines can be viewed here.

Enrolling Physician Contact Information

* required fields

First Name*

Middle Initial

Last Name*

Phone Number*** 10 digits without spaces or dashes (e.g. 8005551212)

Email Address***

(**This email address and phone number will not be publicly viewable and will not be shared or used for any purpose other than to communicate formal program guidelines and materials to you.)

Speciality

Sub-Speciality

Practice Information

* required fields

This will be published online with physician's name and speciality

Name*

Address*

City*

Zip*

Phone Number* 10 digits without spaces or dashes (e.g. 1110005555)

Fax Number* 10 digits without spaces or dashes (e.g. 1110005555)

Web Site

Contact Person, if other than physician

First Name

Middle Initial

Last Name

Phone 10 digits without spaces or dashes (e.g. 111000555)

Enrollment Agreement

I understand that, by submitting this form, I will be enrolled in the Vital Brain program as a "Participating Physician", and my practice information will be included in the Vital Brain's publicly searchable database of care providers. Also, I will familiarize myself with the program's mission and the program's clinical guidelines, "Managing Cognitive Vitality in a Primary Care Setting."

I have read and accept the above Terms and Conditions of Use