Full Name*

Practice Address*

Email*

Cellphone*

NPI (10 digits)*

Preferred Date for the Zoom Meeting* Weekdays only (Monday - Friday)

Timezone* -- Select Timezone -- Eastern Time (ET) Central Time (CT) Mountain Time (MT) Pacific Time (PT) Alaska Time (AKT) Hawaii Time (HST)

Preferred Time* -- Select Timezone First -- All times are based on Eastern Standard Time (EST), weekdays only

Fax Number

Schedule Meeting