Practitioner’s Full Name as you would like it to be viewed on the website – ex: Jane Smith, MD (required)

Additional Practitioner’s Full Name as you would like it to be viewed on the website (separate names with commas)

Practice Name (required)

Practice Address (required)

Other Practice Address (separate each address with a comma)

Practice Website URL (required)

Practice Description (required)

Practice Contact Name (required)

Practice Contact Name Email (required)

Office Phone (required)

EIN – Tax ID (required)

NPI number (required)

Specialty
—Chiropractic CareDermatologyEndocrinologyGastroenterologyNurse PractitionerOB/GYNOrthopedicsPhysician AssistantPodiatryPrimary CarePsychiatryPain ManagementOther

Other Specialty (If “Other” was selected above)

Credentials
—MDDODCNPPAPharmDDPMPTNDRPhOther

Other Credentials (If “Other” was selected above)

Picture of Practitioner(s) (required – Please provide a 600px X 600px JPEG/JPG or PNG image)

Picture of Facility/Clinic – not required (Please provide a 600px X 600px JPEG/JPG or PNG image)

Would you like to participate in our research as a study investigator?
YesNo

Referral code, if applicable