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Name *

Enter your name.

Email *

Enter your email address.

Enter Listing Details

Package *

Featured Physician/Clinic Listing

Basic Physician/Clinic Listing

Select your package.

Has Franchise? *

Yes

Tick "Yes" if listing has franchises.

Lock franchise fields

Select fields to lock from franchise edit.

Personal Contact Info

( Please enter your PERSONAL contact info. )

First & Last Name *

First & Last Name

Personal Phone Number *

Physicians, This Means Your Personal Cell Number, NOT Your Office or Secretaries Phone Number.

Personal Email *

Please Enter Your PERSONAL Email Address, Where We Can Reach Out To You Directly

Business Information

( Please Enter Your Business Information Below )

Physician Or Clinic Name *

Physician Or Clinic Name

Applicant Practioner’s NPI Number *

Please Enter The Applicant Practioner's 10-Digit NPI Number

Physician Bio or Clinic Business Description *

Please Enter In a Bio or Description For Yourself or Your Clinic (I.e., About Us/Me)

Practioner Features *

Select Features That Best Describe You or Your Business (Basic = 3 | Featured = Unlimited)

Category *

All DoctorsFeatured DoctorsFemale PhysiciansLGBTQ+ Friendly DoctorMale DoctorMandarin Speaking DoctorMinority Owned ClinicSpanish Speaking DoctorSpecial Needs Friendly Doctor

Select at least one Category

Default Category *

The default category can affect the listing URL and map marker.

Address *

Please Enter The Physical Address Where Patients Will Visit You

Address line 2 (optional)

Please enter listing Address line 2 (optional)

City *

Click on above field and type to filter list or add a new city.

Zip/Post Code *

Please enter listing Zip/Post Code

Click on “Set Address on Map” and then you can also drag map marker to locate the correct address

Business Hours

Yes

Day	Open 24 hours	Opening Hours	Add

Mon
Tue
Wed
Thu
Fri
Sat		Closed
Sun		Closed
Timezone:

Select your business opening/operating hours.

Phone *

Please Put The Phone Number Of Your Dispensary Here (ex: (888) 888-8888

Business Email *

Please Enter The Contact Email For Your Practice/Clinic (Where Patients Can Reach You At)

Website *

Enter Your Practice/Clinic Website With The https:// included (ex: https://clinic.com

Price *

Enter Your Consultation Price (do NOT add $ symbol)

Business Social Media

( Please Enter The Business Social Media Accounts For The Clinic Or Physican )

Facebook

Enter your business/clinic facebook page url ONLY. Do not enter your personal FB page.

Instagram

Enter your business/clinic instagram url

Please Enter Your LinkedIn Practioner URL

Twitter URL

Please Enter Your Twitter URL (With The https:// At The Beginning)

Twitter Username

Enter Your Twitter Username/Handle WITHOUT the @ – And We Will Add Your Feed Live To Your Listing

Video

Add video url or code here (YouTube, Vimeo, etc.) (*ALL VIDEOS SUBJECT TO LEGAL COMPLIANCE REVIEW AND APPROVAL)

Logo & Images *

Basic Package = Logo + 1-3 Images | Featured Package = Logo + 1-10 images (*ALL IMAGES SUBJECT TO LEGAL COMPLIANCE REVIEW AND APPROVAL)

Drop files here

Allowed file types: .jpg, .jpe, .jpeg, .gif, .png, .bmp, .ico, .webp

(You can upload 10 files)

Please drag & drop the files to rearrange the order

Terms & Conditions *Please accept our terms and conditions

MICA PractionerPlease Select If You Are a MICA Member

Type 64 into this box

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Your Details

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Personal Contact Info

Business Information

Business Social Media

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