Contact Information: for our records only
First name:
Last name:
Company Name: Primary Phone: Secondary Phone: Email address:
Physical/Business address
Mailing address: if different
Other Information: To list you in the Insurance pages and/or the "Where to Find a Practitioner in Your Area" pages
Do you accept Health Insurance:
If Yes, which Insurances do you accept?
What Territory are you in:	Northern Central South East South West Choose One
In what CITY is your practice? List only ONE city
Ad Submission information: If you are NOT going to have a Display Ad complete the Word Ad Only section (you can enter all your Word Ads if you choose to buy more than just one) and then skip to Figuring Your Cost section. If you ARE going to have a Display Ad skip the Word Ad Only section and start with the next section - Display Ad....there is space there to send in the free Word Ad and any additional Word Ads you choose to buy. You will be able to email us your Display Ad at the bottom.f this page.
Word Ad Only - not having a display ad
How many Word Ads do you want?	Only One 2 - Word Ads 3 - Word Ads 4 - Word Ads 5 or more Choose One
Choose Your Heading or Headings from the list See Sample Info.
Add New Heading if you do not see one on the list that fits you
Word Ads: 6 lines of text 2.125" wide We could not size this space to be the exact size so please use your best judgment from the Guide sample or go into MS Word and set it for 2.125" wide with a size 10 Times New Roman font then put that info. here See Samples	See Samples then type your info. here:
Display Ad Information: includes place for free & additional Word Ads Also you can enter text here for a 1/4 page Practitioners Profile Ad
How many Display Ads do you want?	Only One Display Ad 2 - Display Ads 3 - Display Ads 4 - Display Ads 5 or more Choose One
Display Ads: List which size or sizes you want to run
Choose Your Heading or Headings from the list See Samples
Add New Heading if you do not see one on the list that fits you
Word Ads: 6 lines of text 2.125" wide We could not size this space to be the exact size so please use your best judgment from the Guide sample or go into MS Word and set it for 2.125" wide with a size 10 Times New Roman font then put that info. here See Samples	See Samples then type your info. here:
Display Ad Submission:	Please see E-mail/Attach your Display Ad Now at the bottom of this page. This will open an email for you to attach your ad. Please be sure to include your name and phone #.
Figure Cost & Make Payment: Sample... 3 Word Ads Only #1) $35 (Herbs) #2) $25 Reflexology #3) $25 Reiki = Total of $85 OR: 1-1/4 page Display Ad for $173 (Herbs) plus 2 add'l Word Ads (Reflexology & Reiki) for $25 each = Total of $223
Figure Your Cost
How will you be paying today?	Visa Master Card Debit Card Electronic Check Choose One
Notes: Only if needed
Once you push Submit this form will CLEAR....so you may want to make your payment (see Pay Now button below) and attach your ad (see E-mail/Attach Display Ad Now link below) and print a copy of this (for Your records) before you push submit.

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