AHWA - Membership Application

Membership application

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Join The Revolution

This is your first step to becoming part of the Prevention Generation^TM Network

Membership Application

This simple application will be vetted by our board, and we will follow up on your status within 48 hours. If approved for your geography, the next step will be to create your followmydoc.com Page--a “Facebook” style page that defines your practice, specialties and serves as a platform to communicate with patients. The entire process can be completed within 7 days of completing your application.

What type of provider are you?

Holistic

Conventional

Are you a registered provider with CAQH?

Yes

Personal Information

Provider Name *

Provider Email *

Clinic Name *

Clinic Address *

Clinic City *

Clinic State *

Clinic Zip Code *

Office Phone Number *

Mobile Phone Number *

Emergency Contact *

Languages *

Professional IDs

Professional License *

Medicare *

Medicaid *

NPI Number *

Education

Professional School*

Undergraduate *

Other Education *

Professional Training

Other Training*

Faculty Positions*

Specialities

Primary Speciality *

Secondary Speciality *

Additional Speciality *

Certifications *

I accept Terms & Condition *

Join The Revolution Today!

By qualifying for membership, you can lever all aspects of the AHWA to propel your practice with telemedicine, social media and more to drive new patient acquisition and existing patient value.

Apply For Membership