Membership Form

Please complete the following form and submit your photo. It may take up to 5 business days to verify license information and post.

General Info

Your Name (required)

Company Name (Professionals) or School (Students)

Your Email (required)

Credentials

Languages Spoken

Biography

Contact Info

Office Address

Suite#

City (required)

State (required)

Zip (required)

Phone Number (required)

Fax Number

Web Address

Other Info (Professionals Only

Insurance

 Yes No

Type of Insurance Accepted

 In-Network Out-of-Network Flex Plan/HSA Medpay

Colorado License # (required)

Co. License Exp. Date (required)

NCCAOM Certificate #

NCCAOM Exp. Date

Year Graduated (Professionals) or Expected Year of Graduation (Students)

Other Certifications

Practice Details (Professionals Only)

Treatments
 Auricular (ear) Bioset Community Style Clinic Five Element Japanese Korean Medical Acupuncturist Scalp TCM Trigger Point Release Veterinary NA

Techniques & Modalities
 Acupuncture Acupressure Aromatherapy Cupping Diet and Lifestyle Therapy E-Stimulation Gua Sha Herbology Injection Therapy & Biopuncture Laser Medical massage Moxa Magnets N.A.D.A (National Acupuncture Detoxification Association) NAET (allergy elimination) Plasters & Liniments Qi Gong & Chi Kung Tui Na Tuning Forks & Sound Therapy NA

Specialties
 Addiction – other Allergies Arthritis Asthma Autoimmune Disease Colds & Flu’s Cosmetic Chronic Fatigue Dental Dermatology Diabetes Family Practice Fertility Fibromyalgia Gastro Intestinal & Digestive Geriatrics Headache & Migraine Hepatitis HIV & AIDS Hypertension Men’s Health Musculo-Skeletal Neurological Insomnia & Sleep ObGyn Oncology Osteoporosis Pain – Musculo Skeletal Pediatrics Psychological & Emotional Respiratory Sexual Dysfunction Smoking Cessation Sports Medicine Stress, Anxiety & Depression Weight Management Women’s Health NA

Company Logo or Photo (it is best to upload a smaller image around 400px on the longest edge.)