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If you are not a provider and some fields do not apply, enter 0 or N/A or choose the option that fits best.
Username
Only lowercase letters allowed
Password
The password must have at least 6 characters
Email address
First Name
Middle Name
Last Name
Gender
Male
Female
Age
Employer/Organization/Facility (i.e., hospital/clinic name)
Department/Division
License #
(Enter N/A if this does not apply to you)
Credentials
(Enter N/A if this does not apply to you)
Practice Address - street
Practice Address - City
County of practice
Adair
Allen
Anderson
Ballard
Barren
Bath
Bell
Boone
Bourbon
Boyd
Boyle
Bracken
Breathitt
Breckinridge
Bullitt
Butler
Caldwell
Calloway
Campbell
Carlisle
Carroll
Carter
Casey
Christian
Clark
Clay
Clinton
Crittenden
Cumberland
Daviess
Edmonson
Elliott
Estill
Fayette
Fleming
Floyd
Franklin
Fulton
Gallatin
Garrard
Grant
Graves
Grayson
Green
Greenup
Hancock
Hardin
Harlan
Harrison
Hart
Henderson
Henry
Hickman
Hopkins
Jackson
Jefferson
Jessamine
Johnson
Kenton
Knott
Knox
LaRue
Laurel
Lawrence
Lee
Leslie
Letcher
Lewis
Lincoln
Livingston
Logan
Lyon
McCracken
McCreary
McLean
Madison
Magoffin
Marion
Marshall
Martin
Mason
Meade
Menifee
Mercer
Metcalfe
Monroe
Montgomery
Morgan
Muhlenberg
Nelson
Nicholas
Ohio
Oldham
Owen
Owsley
Pendleton
Perry
Pike
Powell
Pulaski
Robertson
Rockcastle
Rowan
Russell
Scott
Shelby
Simpson
Spencer
Taylor
Todd
Trigg
Trimble
Union
Warren
Washington
Wayne
Webster
Whitley
Wolfe
Woodford
Out of state
Practice Address - State
Practice Address - Zip Code
Cell number (optional)
(For KY LEADS internal use only)
May we contact you with KY LEADS-related text messages?
Yes
No
Number of years in practice (since being licensed)
(Enter 0 if this does not apply to you)
Practice size (number of MDs, DOs, PAs, NPs, including yourself)
(Enter 0 if this does not apply to you)
Specialty
Internal Medicine
Family Practice
General Medicine
OB-GYN
Emergency
Other
Primary practice setting
Hospital
Private Practice
Clinic
University
Health System-owned Practice
VA
Public Health Department
Federally Qualified Health Center
Other
Primary practice setting area
Rural
Urban
Suburban
Other
There are required fields in this form marked
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