Register-Affiliate

Affiliate Registration

For Health Professionals only:

* Indicates required field

Name: *

First

Last

Phone #: *

Email: *

Type of Health Professional: *

Name of Practice or Employer: *

Street Address: *

City: *

State/Province: *

Postal Code: *

In what language(s) are you fluent? *

English Spanish Other

If "Other" above, please specify below: *

Have you completed our FREE OptiHealth Affiliate Certificate Course? *

Yes No

Have you participated in any OptiHealth Workshops as a registered Participant of the OptiHealth Network? *

Yes No

I understand by Registering as an OptiHealth Affiliate, I will have unlimited access to the free online Resources and personalized Support available through this website, and that I will also receive the free monthly e-Newsletter regarding Live Workshops over Zoom and locally hosted Workshops in my area. *

Yes

Question or Comment (optional): *

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