kNew Provider Organization
Please complete the following questionnaire so we can refer suitable patients to you.
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What is your first name? *

 
What's your last name? *

 
What are your credentials? *

 
What's your practice address (street, city, state/zip)? *

 
What's your website URL?

 
What's your cell phone number? *

 
Do you practice functional/integrative medicine exclusively? If so, for how long? *

 
Do you have a consultative or primary care practice?


 
What additional services do you offer in your practice?


 
If you offer other additional services, what are they? *

 
What is your practice specialty? *


 
Do you offer telemedicine? *

     
 
Which do you use telemedicine for?


 
How much do you charge (cash) for a 60-minute appointment? *

 
If we need to refer patients to you, how many new appointments could you take in a typical week? *

Thank you so much for submitting the questionnaire, we really your time and effort to complete it thoroughly. Our team will review your submission and follow up with you.
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