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Patient referral service for acupuncture practice Yes, I want to try your service
for FREE!

"There's No Obligation and You Can Cancel Anytime. There's No Reason NOT To Try It."

"I want to try the referral service before I become a member. I understand there’s no obligation and I can cancel any time. Furthermore, I won’t receive any unsolicited commercial emails other than patient inquiries and service announcements. I'm ready to step up!"

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Personal Information:
Salutation:
First Name:
Last Name:
Diploma/Title:
Main Email:
This has to be an active email.
Main Phone:
   
Main Clinic Information:
Clinic Name:
Contact Person:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
If it's different from the main email.
Office Hour:
   
Second Clinic Information
Clinic Name:
Contact Person:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
If it's different from the main email.
Office Hour:
   
Treatment Information
Your Specialties:
If you don't have specific specialties, just enter 'General'. You don't have write long description.
Do you treat ONLY these conditions? Yes.  No. I treat other conditions as well.
Treatment Methods:
   
Website Information
Have a website? Yes, I have a website. No website.
If yes, what's the domain name?
   
   
By submitting this form, I certify that I'm legally certified or licensed to practice acupuncure as required by the the law in the applicable state.