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Practice Name *

Credentials (PT, DPT, OTR, MBA, etc) *

Email *

Mobile Phone Number

Pronouns *

Practice Phone Number *

Address

Street Address *

City

State

Country

Postal code

Appointment Scheduling *

Spoken Languages *

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

Please tell us about your philosophy of care and typical treatment strategies included in the care of a patient with endometriosis (ex: visceral mobilization, myofascial release, yoga therapy, etc) *

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

Waiting time *

Instagram ID

Website URL

Financial Disclosures

Current valid practicing license *

Headshot *

CV *

Which two documents will you upload to prove your endometriosis expertise?

a) Advance Pelvic Health Certificate & b) Signed statement for 50+ hours in last year working with endometriosis patients

a) Two letters of recommendation from endometriosis patients & b) Advance Pelvic Health Certificate

a) Signed statement for 50+ hours in year working with endometriosis patients & b) Two letters of recommendation from endometriosis patients

Advanced Certification in Pelvic Health *

Two letters of endorsement from patients with endometriosis *

Please upload a signed document stating your total number of cases in the last 12 months, the number of endometriosis cases, and the approximate number of hours that you worked with endometriosis patients in the last 12 months *

How did you hear about us? *

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