practitioner account

Name of your Medical Practice*
Website*
Office Contact Name*
First Last
Office Contact Email*
Office Phone Number*
Provider Name*
First Last
licensure*
Other
Provider Address*
Street Address Address Line 2 City State ZIP Code
Provider Email*
Medical License*
Accepted file types: pdf.
Must be PDF
Medical License #*
Copy and Paste your Review Site URLs here:
Column 1
Number of New Patients Per Week*
Please enter a value between 0 and 100.
Number of Active Patients in Practice*
Would you like full integration?
- Yes
- No
This means the supplements you place in your patient notes will be placed in your patient's cart at NutrimentRx
What EMR are you on?
Are You on MD HQ
- Yes
- No
Who is your EMR?
Name of EMR
Your MDHQ URL*

Your MDHQ URL - .md-hq.com/
Patient Portal*

Patient Portal . .md-hq.com/
Medical Practice Aberration*
Example: Functional Medicine Los Angeles would be FMLA
(No Spaces but can use - )
Signature*
By signing this form you agree that all information provided is true and factual. You have authorization to sign on behalf of your medical practice.