IV Micronutrient Therapy Group Intake Form

IVMT Groups.io Intake Form

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This field is for validation purposes and should be left unchanged.
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: 50 MB.

"*" indicates required fields