Please use the form below to register as an affiliate.

First Name:*
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Highest Degree Attained:
Institution Awarding above degree:
Mind body Practice type:
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Professional licenses or registries:*

Do we offer:

Continuing Education? yes no
Phone consultations? yes no
Provide clinical internships or fellowships? yes no
Preferred contact method: phone, email, mail:* phone email mail
Products available in DSR store? yes no
Seminars listed here: yes no
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Background statement: Please submit a brief statement describing yourself, your practice, or your mission.
Referral Info:* current patient prior patient physician internet wellness community desert song

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