Medical Resource Submission Form

Please fill out this form to be considered a a medical resource or facility to be added to GoldCanyon.net's medial resources page.

We will review your information and get back with you shortly.

Medical Facility or Doctor*
Medical Provider Contact Name*
Note -- this information should be the name of the business owner/person who the individual searching would want to reach --- not the Administrative Contact.
First Last
Business E-mail*
Enter Email Confirm Email
Administrative Contact Name
If you are someone who is Administrative Contact for this business and who we should reach if there are questions, instead of the business owner, then please put your contact information here. Note that this name will not be put onto the Business Directory Website.
First Last
Administrative Contact Email
If you are someone who is Administrative Contact for this business and who we should reach if there are questions, instead of the business owner, then please put your e-mail here. Note that this e-mail will not be put onto the Business Directory Website.
Enter Email Confirm Email
Business Phone*
Toll Free Number
If your business has a toll free number you want to list, plese do so here - in addition to the Business Phone listed above.
Business Address*
This is the address of your business.

Street Address Address Line 2 City State ZIP Code
Website for the Business*
Facebook Page Address
If the business has a Facebook Page put the address here.
Twitter Website Address
If the business has a Twitter Account put the address here.
Google+ Website Address
If the business has a Google+ Account put the address here
LinkedIn Website Address
If the business has a LinkedIn Account put the address here
Description of the medical facility or resource*
Please give a couple sentences about what this medical facility or resource does. This should be informative and not a sales pitch.
Please verify. Thank you.