Practitioner Contact/Directory Form

Please fill out this form in it’s entirety so that we can update your contact information in our directory and for our online presence. Please let us know if you are RETIRED, or STILL PRACTICING. If you are Retired, you can skip the business contact information - but we would like to keep in touch with you so please complete the personal contact information.

When filling out this form - for this first time only - please provide ACCURATE and COMPLETE information. We will begin sending this yearly to you with membership dues, and in the future you can fill out “same as last year” if nothing has changed. BUT, if this is your first time completing this form, please fill out everything so that we have a starting base as some of you have changed cities and even countries.