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Practitioner Information Form
Please fill out the following information so that we can get your Choose Health store set up.
Business Name
First Name
Last Name
Email Address
Phone Number
Street Address
City
State
Zip
Your Website or Social URL
(For Affiliate Account Verification)
Payment Preference
Direct Deposit (1 business day)
Check via USPS
(If direct deposit selected)
Bank Routing Number
Bank Account Number
Your Preferred Discount Code
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