Membership Information You have selected the CLINICAL MEMBER - 6 Months membership level. Initial Membership For 6 Months @ $250. Renewal After 6 Months @ $200. Initial payment includes $50 background check. The price for membership is $200.00 now. Membership expires after 6 Months. Do you have a discount code? Click here to enter your discount code Discount Code Account Information Username Password Show Password Confirm Password Hint: The password should be at least twelve characters long. To make it stronger, use upper and lower case letters, numbers, and symbols like ! " ? $ % ^ & ). First Name Last Name Email Address Confirm Email Address Full Name LEAVE THIS BLANK Already have an account? Log in here Personal Details Date Of Birth Phone Number Make sure you put a number here as its used on profile page Address 1 Address 2 City Province/State Postal Code/Zip Code Country Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar, {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Home Phone Number Cell Phone Number Clinical Information Type Of Licenses You Hold ( if applicable ) Example - ND, DC, RN, PA, MD, DO, HMD, APRN Other License Please enter any other license you have here DEA Number ( if applicable ) NPI number ( if applicable ) Business Information Your Business Name Business Phone Number Business Fax Number Business Website Address Example - www.mywebsite.com Business Email Address Business TIN/EIN Business Address Enter your business full address above Services Offered Clincial: List the clinical services you intend to offer to members. Other Business: List the services that your business offers. Education Background Name Of College/University Date Of Graduation College Date From Date College To Date Degrees Earned List all degrees you earned Post-Graduate School Please tell us about any Post Graduate School you attended and if you graduated, what degrees you earned and what were the dates. Upload Your Clinical Training Credentials #1 Upload Your Clinical Training Credentials #2 Upload Your Clinical Training Credentials #3 Upload Your Clinical Training Credentials #4 Any Additional Training or Education Please describe any additional training and education you had Additional Questions Have you ever been convicted of, or pled nolo contender to, a felony or to a misdemeanor involving a crime of moral turpitude? Yes No If Yes, Please Explain: Have you been, or are your currently, the subject of any disciplinary action, against your license(s)? * Yes No If Yes, Please Explain: Has your license been the subject of voluntary surrender, revocation, limitation or restriction? * Yes No If Yes, Please Explain: Has any malpractice or any other lawsuit or settlement, award, or judgement been made against you or your practice? * Yes No If Yes, Please Explain: Do you have any medical condition (e.g., physical, emotional, or psychiatric impairment) that adversely affects your ability to practice medicine? * Yes No If Yes, Please Explain: Are you currently in treatment for a mental illness, drug addiction, or alcohol abuse? * Yes No If Yes, Please Explain: Specialties Here you will list any specialty services you may offer members Add your specialty services you provide enter one specialty per line please Main Specialty You Offer Please enter one short phrase or word for the main specialty you offer, example: acupuncture. This will be shown on your profile page and our members dirtectory Indentification If there is an error or something missing on the form, you will need to upload your attachment again. Upload a copy of your Driver’s License or Government Identification. Upload a copy of your Driver’s License or Government Identification. Upload a photo that meets the following requirements: a. Headshot; and b. Against a White Background. Agreement The Body Membership Agreement The Body Membership Agreement Form must be thoroughly reviewed and accepted prior to submitting your Members Form, along with your electronic signature for our disclosure. The Body Membership Agreement Please click link to open document and read this Agreement. By clicking in the checkbox, you agree to everything on the Body Membership Agreement Agreement The Body Arbitration The Body Arbitration Form must be thoroughly reviewed and accepted prior to submitting your Members Form, along with your electronic signature for our disclosure. The Body Arbitration Please click link to open document and read this Agreement. By clicking in the checkbox, you agree to everything on the The Body Arbitration By Electronically Signing This Form Below You confirm that you have read the "Body Membership Agreement" and "The Body Arbitration" forms provided above. Additionally, you consent to being added to our email list, allowing us to contact you concerning your membership and to send you our newsletters. Your Full Name Processing...
