First Name *

Last Name *

Pronouns *

Credentials (LAC, DAIM, MS, PhD, etc) *

Email *

Practice Name *

Address

Street Address *

City

State

Country

Postal code

Practice Phone Number *

Mobile Phone Number

Appointment Scheduling *

Spoken Languages *

Waiting time *

Total number of cases in the last 12 months *

Number of endometriosis, reproductive, or pelvic health cases in the last 12 months *

Please share the name of the insurance coverages that you accept. Put N/A if you do not accept insurance. *

What is your philosophy of treatment for endometriosis related pain? (This will be published on your profile) *

What do you anticipate might be the benefits of acupuncture therapy for patients with endometriosis? And what are the risks? (This will be published on your profile) *

Financial Disclosures

Instagram ID

Website URL

What should be known about you and/or your practice that we have not asked?

Current valid practicing license *

Please upload two endometriosis patients' letters of recommendation.

10 CEUs related to reproductive health or endometriosis (scan or screen shot of your participation documents)

Please upload a signed document stating your total number of cases and the number of pelvic health cases (endometriosis and reproductive) in the last 12 months

Headshot *

CV *

How did you hear about us? *

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