Clinic Bundle Request
This form is intended to request a minimum of 15 courses  that are placed placed under one purchase order. The clinic bundle offers a 25% discount. If there is a need to include more than 5 providers please complete the form again with the additional provider information. If you have any questions please send us an email before to completing this form.
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Email *
Clinic Information *
Name, website, and full address
Who referred you to purchase this bundle? *
Name and email (if available)
Provider #1 *
Please include name, email, and license number or L-number
Which courses would you like to include for  Provider #1? *
Required
Provider #2 *
Please include name, email, and license number
Which courses would you like to include for  Provider #2? *
Required
Provider #3 *
Please include name, email, and license number
Which courses would you like to include for  Provider #3? *
Required
Provider #4 *
Please include name, email, and license number
Which courses would you like to include for  Provider #4? *
Required
Provider #5 *
Please include name, email, and license number
Which courses would you like to include for  Provider #5? *
Required
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