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LSA ACUPUNCTURE FORM
LSA ACUPUNCTURE FORM 2
Business Information
BUSINESS NAME
*
OWNER'S FIRST & LAST NAME
*
OWNER'S FIRST & LAST NAME
First
First
Last
Last
YEAR BUSINESS WAS FOUNDED
*
PROOF OF INSURANCE - PDF
*
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Maximum file size: 314.57MB
THE FOLLOWING IS NEEDED PER DENTIST
ACUPUNCTURIST FULL NAME
*
ACUPUNCTURIST FULL NAME
First
First
Last
Last
ACUPUNCTURIST EMAIL ADDRESS
*
SERVICES THAT THIS SPECIFIC ACUPUNCTURIST IS LICENSED TO PERFORM:
Acupressure
Acupuncture
Cupping
Gua sha
Heat Therapy
Herbal therapy
Infrared Therapy
Moxibustion
Qigong
Shiatsu
Tui Na
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LICENSE
LICENSE NUMBER
IS THIS ACUPUNCTURIST A BUSINESS OWNER AND/OR SENIOR PARTNER?
YES
NO
WOULD THIS ACUPUNCTURIST LIKE TO BE FEATURED? (If yes, Please send a headshot)
YES
NO
SUBMIT HEADSHOT IMAGE (JPEG, JPG, PNG, TIFF)
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Maximum file size: 314.57MB
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PAYMENT INFORMATION / CREDIT CARD INFOMATION
Billing & Budget Information
BUDGET (Minimum is $306 / Week)
Please specify both the amount and timeline (example: $1,300 per Month)
ORGANIZATION NAME
CARD NUMBER
EXPIRATION
CVC
CARDHOLDER NAME
ZIP-CODE ASSOCIATED WITH THE CARD
If you are human, leave this field blank.
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