Provider Registration

Provider Registration Form
Provider Name*

First NameLast Name
Practice Name / Company Name*
Website *
Business Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Provider Specialty:

Medical DoctorDoctor of ChiropracticDoctor of OsteopathyPANaturopathic DoctorNurse PractitionerMed SpaNutritionistTelemedicineOther
Available Credentials:
NPI Number, License Number, Other
Please upload a photocopy of the license(s) stated above.

Cancelof
Potential Monthly Patient Volume of Genetic Testing:
New to Genetic Testing?

YesNo
Interested In Private Labeling?
Areas of Interest in ExtendingMe US Services:

Foundational PanelOptimal Sleep PanelCustomized Diet PanelFood Intolerance PanelDementia Risk AssessmentPharmacogenomics Panel
■ Women's and Men's Blood Panel (coming soon)
■ Epigenetic Check-up (coming soon)
■ Disease Risk Assessment (coming soon)
Your Business Development Representative:
Name of your ExtendingME Representative
What marketing materials would you like to receive?

Provider Starter Kit (includes 3 kits, a display poster, and 25 patient brochures)Patient Brochures Only
Would you like a Marketing Starter Kit?
Posters, Brochures, and Sample Kits
Should be Empty:

Provider Registration Form