Find A Practitioner Form

To submit yourself or another (by pre-approval only) as a practitioner in our database, please fill out the below form. If submitting on behalf of another, please include that information in the “Notes” field along with further description of your association with the practitioner. If you have any immediate questions, please contact (602) 888-1998.

Fields marked with * are required.

"*" indicates required fields

Submission Type

New Practitioner

Update My Information

First Name*

Last Name*

Your Contact Email*

If we have questions or to reach out.

Your Clinic's Email

If different than your contact email.

Your Phone Number*

Will not be shown if you provide a clinic phone number.

Your Clinic's Phone Number

If different than your contact phone number.

Your Credentials*

Example: “PT, DPT, LMT”

Clinic Name

Clinic Website

Clinic Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Upload a Photo of Yourself

Ideally a head shot. Only numbers and letters in file names.
Accepted image extensions: JPG, JPEG, PNG, GIF

Accepted file types: jpg, jpeg, gif, png, Max. file size: 50 MB.

Practitioner Biography*

Include as much/little about yourself as you’d like. Typically these biographies are written in the third person, listing detailed qualifications and experience. Just remember: People will read this! So, make a stunning first impression! :-)

Notes Regarding Your Submission

If you’d like to leave us a note or ask a question.
Note: This field is private and will not be shown in our public database

Hidden

Old Field Clinic Website

Hidden

Old Clinic Address 1

Hidden

Old Clinic Address 2

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