Thank you for your interest in our service. Registering your clinic is FREE and doing so will automatically enroll you in our 'Practitioner Preview' program which will allow you to experience our service first hand. For more information, click on the 'Practitioner Preview' link to the left.

Within 48 hours of registering, you will receive a confirmation email with details on the 'Practitioner Preview' program.

PLEASE NOTE: After registering your clinic, you can IMMEDIATELY begin registering patients. There is no need to wait until you receive confirmation.

If you have any questions, please don't hesitate to contact us.

Clinic Name *
Clinic Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

The Clinic Address will be used in emails to patients to refer them back to your clinic. If you have an address you would like to use for billing (i.e. a PO Box) please use the billing section below.
Phone 1 * - (###) - ### ####
This is the number we will use when directing patients back to your practice.
Phone 1 Type * Clinic Office Mobile Home Other
Phone 2 - (###) - ### ####
This is a secondary number for contacting you. This will not be shared with patients.
Phone 2 Type Clinic Office Mobile Home Fax Other
Is the billing address the same as the Clinic Address? Same as Clinic Address
Click here if the billing address is the same as the clinic address. The billing address should correspond to your payment method (i.e. if you supply a credit card)
Billing Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

The billing address should correspond to your payment method (i.e. if you supply a credit card)
Practitioner Name * Title First Last Suffix
Middle Initial - Optional

This is not required unless you would like the Practitioner's name displayed with a middle initial.
Practitioner Certifications

Please list any degrees or certifications you would like to appear after the Practitioner's name (i.e. DC, MD, RMT)
Doctor's Name - Short Form for Emails *

This is how you want the practitioner's name to appear within context on the emails (i.e. Dr. Robert G. Johnson might have a short name of Dr. Johnson, Robert or Dr. Bob). An example would be, "Ask Dr. Bob about what protocol would be best for you."
Clinic Web Site
Clinic Email Address *

This is the main address for your account and will be the address you use when registering patients.
Patient Support Email Address

If you provide patient support by email, please provide the appropriate email address here. If this field is left blank, we will NOT share your email address with your patients.
Please list any staff authorized to sign up patients
Staff Member 1 / Billing Contact Title First Last Suffix
If the practitioner is not the billing contact, please supply Billing Contact details here.
Staff Member 1 Email
Staff Member 2 Title First Last Suffix
Staff Member 2 Email
Staff Member 3 Title First Last Suffix
Staff Member 3 Email
Staff Member 4 Title First Last Suffix
Staff Member 4 Email
Staff Member 5 Title First Last Suffix
Staff Member 5 Email
Are you currently a student? No Yes
We are working to customize our services to best suite our clientele. We would like to roll out services specifically for students. By indicating you are a student we will keep you informed of services available to you and programs/presentations that Standard Process might be offering at your school.
Anticipated Graduation Date / MM / DD YYYY
If you are a student, please indicate your anticipated graduation date.
School Name

If you are currently a student, please indicate the name of your school.
Purification Specialist - "Detox Friend"

We have an on-staff Purification Specialist, Allison, who is available to assist you and your patients at no additional cost during the 21-day support program. Allison is available to provide general direction such as recipe suggestions, help troubleshoot simple difficulties that may arise during the Purification Program and provide answers to questions about the daily email suggestions. In addition, we are finding that patients love having a “Friend” they can talk to during the 21 days. This service is highly recommended and helpful in increasing patient compliance and contentment. Please note that Allison does not dispense clinical advice, her recommendations are strictly focused around the 21-Day Program and that she directs patients back to your clinic for any questions regarding their health concerns. This service should help take the load off of you and your clinic in answering numerous basic questions that arise during the 21 days and provide a personal contact to encourage them. | If you choose to take advantage of this service, a note will be included at the bottom of each email indicating that if the patient has questions about suggestions in the email or the purification program in general, they can email her. Your patients will also receive a welcome email from Allison on Day 1. | You can opt-in or out of this service at any time. If you aren’t sure, remember that you can experience this first hand during the Practitioner Preview program and if you choose not to use it you can opt-out later.

Would you like this service available to your patients?
Purification Specialist * Yes No
How did you hear about our service? *
Comments

If you have any comments or special instructions, please let us know.

Please list any staff authorized to sign up patients

Purification Specialist - "Detox Friend"