Practitioner Interest Form
This information will help us understand a little bit more about you and your practice. As the project gets started, we will reach out to discuss the project and help determine if you and your practice would be a good candidate for our research study.
Section 1: About You
Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Best Contact Phone Number
*
Please enter a valid phone number.
Preferred Contact Method
Email
Phone
Text (SMS)
What is your experience with acupuncture? Do you hold any certifications or credentials related to it?
*
What is your experience with Tui-na (Chinese medical massage)? Do you hold any certifications or credentials related to it?
*
Section 2: About Your Hospital
Hospital Name
*
Hospital Location
*
Brick & Mortar
Mobile
Hybrid (Both)
Hospital Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Average number of canine patients with confirmed coxofemoral (hip) osteoarthritis/degenerative joint disease seen each month?
*
Do you have staff available to assist with taking photos, videos, and/or Tui-na instruction?
*
Yes
No
Are you and/or your staff comfortable using a personal cell phone to take photos and videos as well as uploading information to be sent by email or saved in cloud storage (i.e. Dropbox, Google Drive)?
*
Yes
No
Any additional notes/comments?
Please verify that you are human
*
Submit
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