New PractitionerUpdate to Existing Practitioner Your Name (required) Credentials Date Clinic Address Phone (required) Fax Practitioner Email (required) Website Social Media Links Practice Emphasis Qualification Institution where qualification was obtained Qualification Year How did you hear from us? (Please select one) Referred byInstitute of Integrative MedicineEmailWeb SearchConference / EventOther If Conference, please fill in: Conference / Event Name If Referred, please fill in: Referred by (please specify) If Other, please fill in: Other (Please specify) Become a Functional Medical Practitioner Use this discount coupon code: biometrix while checking out, and you will receive a 10% discount on your purchase. Apply here: www.iim.health/ref/biometrix/ Reporting Biometrix Labs sends report results directly to the Practitioner's Preferred email address for reports (required) Billing Patients pay Biometrix Labs directly or Biometrix Labs can bill the practice Subject Any Further Details I consent to the processing of my personal information under the "Protection of Personal Information Act, 2013 (POPI)" in line with Our Privacy Policy I consent to the conditions.
