Provider Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

We will not publish this if you don't have a physical address where you provide services

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Scope of Practice *

Which of the following best describes your services?
(Select all that apply)

Ayurveda

Acupuncture

Traditional Chinese Medicine

Naturopathic Medicine

Body Work

Energy Work

Counseling

Herbalism

Farmer

Grocer

Pricing & Insurance *

Which of the following payments do you accept? (Select all that apply)

Insurance

Cash

Checks

Credit Cards

Debit Cards

HSA/FSA

Paypal

Venmo

Zelle

Crypto Wallet

*

If it became available in your field, would you be open to taking insurance?

Yes

No

*

Do you use an EHR? (Electronic Health Records)

Yes

No