FHP Application

Thank you for your interest in FHP.
Please complete the following application, and we will get back with you as soon as possible.

Applicant Information

First Name *

Last Name *

Phone *

Email *

Postal Code *

Time Zone *

Professional Background

What is your primary credential? *

MD, DO, NP, PA, DC, RD, Health Coach, etc.

Years in clinical practice *

What is your functional medicine experience? *

Have you ever been subject to disciplinary action or licensing restrictions? *

Yes

No (please explain below)

Disciplinary action/licensing restriction explanation.

Please provide a link to your website or professional profile.

Please upload a copy of your Curriculum Vitae

Membership Interest

Which membership(s) are you interested in? *

Connect (social only)

Coach (non-prescribers)

Clinician (prescribers)

Entrepreneurial Stage

Where are you currently in your business-building journey? *

Entrepreneurial stage "Other" response:

Do you currently have an EMR? If so, which one? *

Practice Vision

What type of practice are you building? *

Solo micropractice, hybrid, virtual-only, integrative clinic, coaching-based, specialty-focused, etc.

Which populations or specialties do you focus on? *

Goals & Expectations

What are you hoping FHP will help you with? *

Goals & Expectations "Other" response:

What would “success” in your first 6 months with FHP look like? *

Skills & Readiness

Comfort with technology *

Tech-avoidantVery Comfortable

Organizational Style *

ChaoticHigh Organized

Commitment & Fit

FHP is a collaborative community for independent but supported clinicians. What draws you to this type of model? *

Are you interested in contributing resources, teaching, or supporting other members? *

Yes

No

Maybe

Are you willing to follow shared standards (HIPAA compliance, EMR etiquette, respectful communication, etc.)? *

Yes

No

Are you open to shadowing, mentorship, and community case discussions? *

Yes

No

Maybe

Other

How did you hear about FHP? *

Referral (please specify name below)

Social media

Google search

Other (please specify)

Referral name or "other"

Do you have any other comments or questions you'd like to share?

Captcha

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