Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Please check your licensed profession:
*
Physical Therapist
Certified Lymphatic Therapist
Occupational Therapist & Certified Lymphatic Therapist
Nutritionist
Mental Health Professional
Other
Name
*
First Name
Last Name
Please list any post-nominal credentials:
*
ex: PT, DPT, LCSW
Where are you certified?
*
List any additional states you maintain certification:
Have you worked with lipedema patients?
*
Yes
No
If no, are you willing to learn about lipedema and how your profession can be helpful to lipedema patients?
*
Yes
No
Email
*
Work Number
*
Format: (000) 000-0000.
Mobile Number
*
Format: (000) 000-0000.
Name of Practice
*
How long have you worked in your profession?
*
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Practice Website
*
Please upload your CV, Resume and/or business card
*
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