Doctor Membership

Doctor Membership

Membership Application
Personal Details
*
First Name
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*
Last Name
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*
Email Address
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This will be your login username
*
Password
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Please enter at least 6 characters.
    Strength: Very Weak
    *
    Full Name
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    How your name will appear to other members
    Headshot photo
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    Please upload a headshot
    *
    About You
    Biography can not be left blank.
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    Please provide a brief bio (visible to other members)
    Public Email
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    Visible to other members
    Public Phone #
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    Visible to other members
    *
    Your Mailing Address
    Text field can not be left blank.
    Please enter valid data.
    Street, City, ZIP (Will remain private)
    Education Details
    *
    Accredited School Name
    Text field can not be left blank.
    Please enter valid data.
    *
    Graduation Year
    Field can not be left blank.
    Please enter valid year.
    Please enter at least 4 characters.
    Maximum 4 characters allowed.
    Please enter valid year.
    *
    Are you licensed as an ND in another state?
    YesNo
    Please select one option.
    Please enter valid data.
    If, yes, which state?
    Text field can not be left blank.
    Please enter valid data.
    Please enter valid data.
    License #
    Text field can not be left blank.
    Please enter valid data.
    List professional licenses you hold.
    This Field can not be left blank.
    Please enter valid data.
    Please specify when licensed and where.
    Practice Info
    *
    Practice Name
    Text field can not be left blank.
    Please enter valid data.
    *
    Practice Description
    This Field can not be left blank.
    Please enter valid data.
    Practice Specialties
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    Separate each by comma
    *
    Practice City
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    Practice Website (URL)
    Website (URL) can not be left blank.
    Invalid URL
    Invalid URL
    Practice Phone #
    Text field can not be left blank.
    Please enter valid data.
    Does your practice have a residency program?
    YesNo
    Please select one option.
    Please enter valid data.
    Certification
    *
    Upload copy of diploma from accredited Naturopathic Medical school
    Please select file.
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    Invalid file selected.
    *
    Upload copy of current Naturopathic Medical License
    Please select file.
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    Socials
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    Select Your Payment Gateway
    How you want to pay?
    Payment Summary

    Your currently selected plan : , Plan Amount :
    Coupon Discount Amount : , Final Payable Amount:
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