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Application to Join: Provider Registration




First Name

Last Name

Store Name*[your_store]

Address 1*

Address 2





Store Phone*

Is the address above your home address? (Home address will not show on your profile)*

Name(s) of primary owners*

Date of birth of the primary owners*

Who can we thank for referring you to You Define Wellness?*

For all practitioners at this location, has any license or registration to practice within any jurisdiction ever been sanctioned, revoked, placed on probation, fined or penalized, suspended or been limited in any manner, or is any such action pending?*

Have any practitioners ever been convicted of a felony or misdemeanor, or is any such action pending?*

Are you now, or have you ever been involved in a malpractice suit, including arbitration, or has any malpractice claim or settlement not involving litigation or arbitration, ever been paid by you to be paid on your behalf?*

If your answer to any question above is "Yes" and you have not already been pre-approved, explain 'yes' answers below..

Is your office HIPAA compliant?*

Education/Certifications for your modality

Licenses regulated by the state & license number

The information provided herein is true and accurate to the best of my knowledge. I have received a copy of the Provider Agreement and agree to its terms.*

I/we understand that all pictures uploaded to our store page and/or products must be owned by us or created by You Define Wellness.*

Electronic Signature (enter your name below)*


Confirm Password*

* Agree  Terms & Conditions

Application to Join: Provider Registration June 26, 2020