Wellory Network Enrollment Form

An active Registered Dietitian license is required to join the Wellory Provider Network. Do you hold an active RD license?* This field is required.National license must be issued by the Commission on Dietetic Registration. We’ll ask about state-specific and state-issued licenses later!

Yes

Before you continue!

Do you have the items below on-hand?

In this form, you will be asked to share/upload copies of the below items.

RD/RDN License. This is the license provided to you by the Commission on Dietetic Registration. Your license must be active in order to join the network. You will need to upload a copy of this to complete the form.
State Licences (if applicable). If you have state-issued licenses, you will be asked to upload copies of these in the form.

Need to secure one or more of the above items? We recommend waiting to begin this form until the items are secured.

Questions? Email providers@wellory.com – we're here to help!

Full Name* This field is required.Please enter your full name, as it appears on your RD license.

First Name

Last Name

The next question will ask you for your email. Here's how to save your responses as a draft and access it at any time via email! (HINT: download this PDF to access instructions later!) Review these steps before proceeding to the next question.

Email Address* This field is required.If you save your responses, a link will be emailed to you where you can access this form at any time.

example@example.com

On average, how many hours per week are you available to support clients?* This field is required.Do your best to provide an estimate – this number can increase or decrease over time, and you'll always have control over your own calendar availability.

How many years of experience do you have in the nutrition field?* This field is required.

What's your individual NPI? (If you don't yet have one, input "0" or follow the link below to obtain one!)* This field is required.Don't have an NPI? Copy and paste the following link for instructions: http://bit.ly/3l6oNWX

What's your Commission on Dietetic Registration License Number? (RD, RDN)* This field is required.Please enter the license number provided to you by the Commission on Dietetic Registration.

What's your CDR RD/RDN License Start Date?* This field is required.

What's your CDR RD/RDN License Expiration Date?* This field is required.License must be currently active in order to be credentialed.

Please upload a copy of your RD/RDN License issued by the Commission on Dietetic Registration.* This field is required.License must be currently active in order to be credentialed.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Note: ".HEIC" files are not supported. Please upload a PDF, PNG, or JPEG. If you have a .HEIC on your desktop, try taking a screenshot of it in order to convert it into a supported file type.

How many State-Issued Nutrition Licenses do you hold? (ie: CDN)

More Than 3

In which of the following states do you hold an active state-issued license? (You must have a license number to provide along with a copy of the license.)* This field is required.Select only states where you hold an active license and can provide your license number.

(Please skip this question if you completed the prior question) Please list the state(s) in which you are licensed.Please only list states in which you hold active licenses

Please separate multiple states using a comma.

Please share the license number, issue date and expiration date for all state licenses you hold.* This field is required.

Please upload a copy of each of your state-issued licenses.* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

State License Number

If you have multiple state licenses, please provide only the first state license number here. You will be asked for additional license numbers in the following questions.

State License Start Date

Date

State License Expiration DateLicense must be currently active in order to be credentialed.

Date

Please upload a copy of your State Provider License.License must be currently active in order to be credentialed.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Note: ".HEIC" files are not supported. Please upload a PDF, PNG, or JPEG. If you have a .HEIC on your desktop, try taking a screenshot of it in order to convert it into a supported file type.

State License Number (#2)License must be currently active in order to be credentialed.

State License Start Date (#2)

Date

State License Expiration Date (#2)License must be currently active in order to be credentialed.

Date

Please upload a copy of your State Provider License (#2) License must be currently active in order to be credentialed.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Note: ".HEIC" files are not supported. Please upload a PDF, PNG, or JPEG. If you have a .HEIC on your desktop, try taking a screenshot of it in order to convert it into a supported file type.

State License Number (#3)

State License Start Date (#3)

Date

State License Expiration Date (#3)License must be currently active in order to be credentialed.

Date

Please upload a copy of your State Provider License (#3)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Note: ".HEIC" files are not supported. Please upload a PDF, PNG, or JPEG. If you have a .HEIC on your desktop, try taking a screenshot of it in order to convert it into a supported file type.

What's your CAQH Number? (If you do not yet have a CAQH account, input "0" or follow the link below to obtain one)* This field is required.If you do not have a CAQH number, copy and paste the following link for instructions on how to obtain one: http://bit.ly/3J5EAgk. This is a 2-minute process!

What are your nutrition specialties?* This field is required.Select all that apply – the more, the better!

Autoimmune Disease

Cancer

Depression

Diabetes Type 1

Diabetes Type 2

Gestational Diabetes

Eating Disorders

Emotional Eating

Food Allergies/Intolerances

Gut Health

Healthy Aging

Heart Health/Cardiovascular Disease

High Blood Pressure

Hormone Imbalance

Intuitive Eating

Ketogenic Diets

Kidney Disease

Liver Disease

Men's Health

Women's Health

Pediatric Nutrition

Pre/Post-Natal Nutrition

Thyroid Disorders

Vegetarian/Vegan

Weight Management

Wound Healing

What languages do you speak fluently?* This field is required.Please only select languages you are comfortable supporting clients in.

English

Spanish

Mandarin

Cantonese

Hokken

Tagalog

Vietnamese

French

Arabic

Korean

Russian

Italian

German

Portuguese

How did you hear about Wellory?* This field is required.

Which Wellory provider referred you to Wellory?Please share their name so that we can give them referral credit!

Please share how you heard about Wellory.* This field is required.