IV Micronutrient Therapy Group Intake Form

IVMT Groups.io Intake Form

If you were a part of the IVMT Yahoo Group, you do not need to fill this out again as you have already been vetted.
If you have any questions, please reach out to IVMT+owner@groups.io
1. Your full name with post-nominal letters.*
First Last post-nominal letters
Email*
2. The medical school you went to AND the year you graduated.*
If you are a student, include your anticipated graduation date
3. The state you are licensed in AND your license number.*
If you are a student, state you are a student.
4. Your specific educational credentials in IV micronutrient therapy, including when, where, and from whom. Note: this means formal CME / CE approved education.*
5. IF YOU ARE NOT A LICENSED PRESCRIBER (or student), provide the name of the prescriber member under whom you carry out orders.
Please upload a scanned copy of your license*
Max. file size: 64 MB.
Comments
This field is for validation purposes and should be left unchanged.

Student or Professional

Licensed Physicians and Health Care Professionals

Students, Residents, and First Year Graduates

2 Day or 4 Day

4 Day (In-Person Only)

2 Day (In-Person & Livestream)

Printed Seminar Manual*

Printed Seminar Manual for In-Person Pickup - $75

Printed Manual + Shipping $85

Digital Notes Only

Name(Required)

Title First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Licensing Credential(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Livestream or In-Person

Livestream

In-Person

4 Day - Professionals

Seminar registrants must have a current license to practice medicine (ND, MD, DO, NP, PA, RN).

Price:

4 Day - Student

Price:

2 Day - Professionals

Seminar registrants must have a current license to practice medicine (ND, MD, DO, NP, PA, RN). THIS IS FOR DAYS ONE AND TWO OF THE SEMINAR ONLY.

Price:

2 Day - Student

THIS IS FOR DAYS ONE AND TWO OF THE SEMINAR ONLY.

Price:

Printed Seminar Manual for In-Person Pickup - $75

Price:

Printed Seminar Manual for Shipping - $85

Price:

Group Code

Total

"*" indicates required fields

Registration Type*

Professional - $1000

Student -$800

Livestream or In-Person*

Livestream

In-Person

Printed Seminar Manual*

All attendees will receive Digital (PDF) notes.

Printed Manual For In-Person Pickup - $75

Printed Manual + Shipping - $85

Digital Notes Only

Attendee Title:

Attendee Name*

First Last

Licensing Credential or Student:*

Attendee Email*

Attendee Phone Number:*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

How did you hear about us?

LICENSED PHYSICIANS AND HEALTH CARE PROFESSIONALS

Price:

STUDENTS, RESIDENTS, FIRST YEAR GRADUATES

Price:

Printed Manual For In-Person Pickup

Price:

Printed Manual + Shipping

Price:

Total

IV Micronutrient Therapy Group Intake Form

IVMT Groups.io Intake Form

Additional Information

IV Nutritional Therapy Blog

WHAT IS IV NUTRITIONAL THERAPY?

Vertisis Custom Pharmacy

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TransLite LLC

McGuff Family of Companies

SterileDrugs.com

Doctor’s Data, Inc.

Simply O3

Merit Pharmaceutical

Perfect Balance

AMARC Enterprises / POLY-MVA

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