HEALTH GUIDE SUBMISSION FORM

Please complete this form for your Physician Profile to appear in the January 2021 issue. Submission deadline is November 20, 2020.

Name of physician practice
*Please give us the name you’d like to be published in your profile.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
*Please give us the full street address you’d like to be published in your profile.
Phone
*Please give us the contact information you’d like to be published in your profile.
Website

*Please give us the contact information you’d like to be published in your profile.
Profile Text
*Please provide 75 words for a quarter-page profile, 125 words for a half-page profile, or 150 words for a full page-profile. Profiles will be edited for length, as well as tone/style. No logos will be included with profiles.
Contact
*Please provide the name and e-mail address for the person we should contact with questions about your profile.
Contact Name*
First Last
Contact Email*

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