Practitioner Information Form

New PractitionerUpdate to Existing Practitioner

Your Name (required)

Credentials

Date

Clinic

Address

Phone (required)

Fax

Practitioner Email (required)

Website

Social Media Links

Practice Emphasis

Qualification

Institution where qualification was obtained

Qualification Year

How did you hear from us? (Please select one)

Institute of Integrative MedicineEmailWeb SearchConference / EventReferred byOther

If Conference, please fill in:
Conference / Event Name

If Referred, please fill in:
Referred by (please specify)

If Other, please fill in:
Other (Please specify)

Reporting
Biometrix Labs sends report results directly to the Practitioner's
Preferred email address for reports (required)

Billing
Patients pay Biometrix Labs directly or Biometrix Labs can bill the practice

Subject

Any Further Details

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I consent to the conditions.