CONTACT US Contact Us Name * FIRST NAME Last * LAST NAME Email * EMAIL ADDRESS Contact Phone Number Phone Number Business Name Business Name Website WEBSITE URL Professional Designation MD/DO Naturopath Nurse Practitioner Physician Assistant Nutrition Professional Acupuncturist Chiropractor Health Coach Other Do you own your own practice? Yes No Are you in group practice or work for a hospital? Yes No Are you starting your practice from scratch? Yes No Are you currently practicing functional medicine? Yes No If you are practicing functional medicine, how much of your time is devoted to functional medicine? 100% 75% 50% 25% Only on Friends & Family Do you currently accept insurance Yes No Is your vision of your Perfect Practice to move from insurance to all cash pay? Yes No Is your vision of your Perfect Practice to move from insurance only to a hybrid model of insurance and cash? Yes No Do you currently sell supplements or other products at your office? Yes No How many employees are on your team? Me only 1- 4 5 - 9 10+ Tell us about your practice and your vision for your perfect practice. * GIVE US A DESCRIPTION OF YOUR CURRENT PRACTICE. How did you hear about us? Referral From a Colleague Our Website Social Media Search Engine Referral Partner Met at a Conference reCAPTCHA Δ
