Patient Registration

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First Name (*)

Last Name (*)

Country (*)
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Your Practitioner’s Name, Address, Phone #, email, web address and (license # if available)*

Your Practitioners Specialty
MD (Doctor of Medicine)PA (Physician’s Assistant)ND (Naturopathic Physician)DDS (Doctor of Dental Surgery)RN (Registered Nurse)DC (Doctor of ChiropracticDO (Doctor of Osteopathy)DVM (Doctor of Veterinary Medicine)OMD (Doctor of Oriental Medicine)Lac (Acupuncturist)PT (Physical Therapist)MT (Massage Therapist)CDN (Certified Dietician / Nutritionist)Phytotherapist / HerbalistOther/No Practitioner: (fill in Comment Box please)

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