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Practitioner Application

* Indicates required field

Gender *

Male Female

Name of Practice *

Resale License # *

Specialty or Field *

Practitioner License # *

Title *

Name of Practitioner *

First

Last

Phone Number *

Contact Email *

Postal Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

Birth Year *

Birth Month *

Birth Day *

Upload Photo *

Max file size: 20MB

Upload a fairly recent photo showing your face that we can use online.

Practice Goals *

Who may we thank for referring you? *

Please let us know how you found us, whether referred by a practitioner, a trusted friend, or one of our books...

Checking the box below allows us to send you our newsletter occasionally or periodically...

Website URL *

Current modalities include: *

Nutritionals/Probiotics Botanicals Homeopathics/Essences PEMF Microcurrent Photobiomodulation/Light/Color/Infrared Biofeedback Functional Response Testing/Electrodermal Screening/Muscle Testing Other (describe below)

Please list other specialties including diagnostics like OCT, thermography, dark adaptation, macular pigment, contrast sensitivity, etc.: *

Remedy Resale:

Ordering: Please order by email.
MOQ: The minimum wholesale order is 6 bottles of any combination of remedies.
Shipping:  The typical shipping and handling cost by USPS runs about $1 per bottle for most products anywhere in the States. Inquire for foreign shipments.
MAP:  The Minimum Advertised Price is the suggested retail price, so you won't have to compete with discount marketers...
Online Sales:  Online sales are permitted on your own website, and not on any 3rd party sites such as Amazon.

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Home
Pricing
Consult
- Application
- Animal
Store
- Shop >
  - Supplements >
    
    Homeopathics
  - NES >
    
    Infoceuticals >
    
    FeelGood Infoceuticals
  - Zyto
  - Water
  - Kitchen
  - Skin Care
  - Eye Care
  - Dental
  - Local Services
  - Remote Services
  - Print Books
  - Ebooks
  - DVDs
  - Music CDs
Links
Contact
Search
About

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