2020 Conference Attendee

Price:

Free

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

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City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Full name with Credentials (as it should be displayed): Full name with Credentials (as it should be displayed) is not valid

Primary profession applying under:* Primary profession applying under is Required

State/territory you practice in, and license/certification number (if applicable, can list multiple): State/territory you practice in, and license/certification number (if applicable, can list multiple) is not valid

If you are licensed, please list the issuing body who governs your licensure.: If you are licensed, please list the issuing body who governs your licensure. is not valid

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Personal Phone:* Personal Phone is Required

I am a member of the general public (not a clinician, allied healthcare provider, student, or representing a business)*

Office Full Address (for directory listing, if applicable):: Office Full Address (for directory listing, if applicable): is not valid

Office Phone (for directory listing, if applicable):* Office Phone (for directory listing, if applicable) is Required

Office Email (for directory listing, if applicable):* Office Email (for directory listing, if applicable) is Required

Website URL (for directory listing, if applicable): Website URL (for directory listing, if applicable) is not valid

Office Information: Office Information is not valid

Accepts Insurance Accepts Medicare Accepts Medicaid Superbill Only Consultations Online Consultations by Phone

Highest level of education:* Highest level of education is Required

Are you actively practicing in the field of environmentally acquired illness (EAI)? If yes, for how long?:* Are you actively practicing in the field of environmentally acquired illness (EAI)? If yes, for how long? is Required

Please list any EAI-related training or certification: ADAPT (Kresser), Bredesen, CIRS, IFM, ILADEF/ILADS, etc - provide specifics if needed:* Please list any EAI-related training or certification: ADAPT (Kresser), Bredesen, CIRS, IFM, ILADEF/ILADS, etc - provide specifics if needed is Required

In addition to above, who are the most influential teacher(s) or institution(s) you have been affiliated with in the EAI field? Please tell us about your association with them.:* In addition to above, who are the most influential teacher(s) or institution(s) you have been affiliated with in the EAI field? Please tell us about your association with them. is Required

Please provide any other information about your professional experience in the EAI field, personal interests in EAI (if any), and any other background information you wish to share:* Please provide any other information about your professional experience in the EAI field, personal interests in EAI (if any), and any other background information you wish to share is Required

Please provide any information about your interest in environmentally acquired illness and/or any other background information you wish to share: Please provide any information about your interest in environmentally acquired illness and/or any other background information you wish to share is not valid

Do you currently carry prescriptive rights in the state/territory you actively practice in?: Do you currently carry prescriptive rights in the state/territory you actively practice in? is not valid

Prescriptive rights details: Prescriptive rights details is not valid

If practicing outside of the US, please describe the scope and details of your prescriptive rights: If practicing outside of the US, please describe the scope and details of your prescriptive rights is not valid

General educational/professional experience:* General educational/professional experience is Required

Other areas of special interest/expertise:* Other areas of special interest/expertise is Required

Statement of medical or health professional board action(s): Statement of medical or health professional board action(s) is not valid

Malpractice history: Malpractice history is not valid

Willingness to participate on committees or projects set up by the Board:* Willingness to participate on committees or projects set up by the Board is Required

Inclusion on internal referral list?:* Inclusion on internal referral list? is Required

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Instagram Profile URL: Instagram Profile URL is not valid

Twitter Handle: Twitter Handle is not valid

Website: Website is not valid

Include me on the ISEAI Supporters page (y/n, list URL if desired): Include me on the ISEAI Supporters page (y/n, list URL if desired) is not valid

Is there someone we can thank for your referral? Are they an ISEAI Member?: Is there someone we can thank for your referral? Are they an ISEAI Member? is not valid

If not, how did you hear about ISEAI?: If not, how did you hear about ISEAI? is not valid

Promo Code: Promo Code is not valid

Practice or Business Name:* Practice or Business Name is Required

If n/a, please explain professional association:: If n/a, please explain professional association: is not valid

Describe your professional scope of practice:* Describe your professional scope of practice is Required

Agree to operate solely within my professional scope of practice while interacting on the ISEAI Forum and during Webinars and Conferences*

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I have read and agree to the Terms Of Service.*

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2020 CONFERENCE

One People, One Planet, One Health
October 2-4, 2020

2020 Conference Attendee

About the Author: ISEAI Admin

iseainonprofit

2020 CONFERENCE

One People, One Planet, One Health October 2-4, 2020

2020 Conference Attendee

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About the Author: ISEAI Admin

One People, One Planet, One Health
October 2-4, 2020