If you would like to register as a partnered healthcare provider or a distributor, please fill out the form below: Partnered Healthcare Provider and Distributor Application Please fill out the form below to apply as a partnered healthcare provider or a distributor. Are you a healthcare provider, distributor, retailer, or something else?Healthcare ProviderDistributorRetailerSomething elseWhat is the name of your practice or company?* What kind of healthcare provider / practitioner are you?*Select one from the listAcupuncturistChiropractorCertified NutritionistDoctor of MedicineDoctor of Naturopathic MedicineDoctor of Oriental MedicineDoctor of Osteopathic MedicinePhysician's AssistantRegistered DieticianRegistered NurseRegistered PharmacistNone of the above / OtherWhat state are you registered in?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificTell us what kind of healthcare provider you are Are you a member of any association for naturopathic doctors? Please list the name of any organizations you are a member of.File Upload: Credential Document*Please attach a copy of your practitioner license. Please note that the maximum file upload size is 16MB.Max. file size: 16 MB.Do you plan to sell our product online?*YesNoEmail* Name* First Last Is there a website where we can learn more?Please provide a link to your practice or business File Upload: Brochures etc.Upload any brochures, presentations, leaflets etc. which might help us know more about your business or practice. Please be aware that the max file upload size is 16MBMax. file size: 16 MB.Tell us about your proposal!CommentsThis field is for validation purposes and should be left unchanged.
