IASIS Technologies - Provider Information

First Name

Last Name

Personal Cell Phone (For IASIS only, to communication directly with you) *

When is the best time to contact you for a phonecall?

Weekday AM (9-11:30 PST)
Weekday PM (1-6 PST)
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Personal Email (For IASIS only, to communication directly with you) *

Profession

Choose 1

MD
DO
DDS
DC
PHD
PsyD
ND
NP
PA
RN
L.Ac
LPC
LCSW
LMFT
LCDC
PT
OT
EMS
Mental Health/Other
Therapist/Other
Veterinarian
Other
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Provisional Under (*If non-licensed write the name of Licensed provider overseeing you)

Business Info

Name of Business/Practice

Office Phone Number

Website

Business Address

Address

City

State

Postal code

Billing Information

Billing Name

Billing Street Address

Billing City

Billing State

Billing Postal Code

Shipping Address

Method of Payment

Wire
Credit Card
Financing
Check
ACH
Zelle
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Shipping City

Shipping State

Shipping Postal Code

Shipping Address

Shipping address is at a

Commercial Building

Residence

Please upload a copy of license or take a picture and attach it here

Purchasing & Training

Copy of License / Provider Sheets

Training - Primary Trainee

Training- Secondary Trainee

Secondary Trainee Email

Secondary Trainee Cell Phone Number

I am interested in Onsite Training (Onsite training involves a certified trainer coming to your office or location to deliver an FOI training program. *Extra fee associated with this service. Contact office for details

Yes, ASAP

Yes, in near future

No, not at this time

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