Add Non-Dental Holistic Practitioner Form

Contact Information
Title
Provider’s First Name
Provider’s Last Name
Company Email
Date Entered Into System
Assistant Name
Assistant Phone
Billing Information
City
Company
Person Notes
Assistant’s Email
Main Fax
Nickname
Company Phone
Company Phone Ext
Cell Phone (assistant’s)
Company Phone 2 Ext
Postal Code
State
Street Address 1
Street Address 2
Website
Miscellaneous
Check all that apply: Accupressure

Accupuncture

Aesthetician

Allergists

Alphabiotics

Aromatherapy

Ayurvedic Practitioners

Biofeedback

Botox

Brainwave Therapists

Chelation Therapists

Chiropractic

Colon Hydrotherapists

Cranialsacral Therapists

Day Spa

Detox/Cleansing Therapists

Dieticians

Energy Healers

Herbal Practitioners

Holistic Health Practitioners

Homeopathic Doctors

Hypnotherapists

Life Coaches

Lymphatic Therapists

Massage Therapists

NAET Therapists

Naturapathic Doctors

Nutritional Practitioners

Optometrists

Osteopathic Doctors

Personal Trainers

Physical Therapists

Reflexology

Reiki

Rolfing

Skin Care

Spa

Tui Na

Yoga

Physicians

OTHER

Rating – Level 1

Rating – Level 2

Rating – Level 3

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