Name *

First

Middle

Last

Name of practice *

Type of healthcare provider *

NPI number (individual) *

Used to verify as healthcare provider

Mobile phone *

We will only contact your mobile for your appointment scheduling and confirmations. We do not share your info.

Email *

We will only use your email for your appointment scheduling and confirmations. We do not share your info.

Reason for contacting us *I'd like to schedule my complimentary appointmentI'd like you to send me massage referral pads and/or business cards for your office (please specify which below)I have a specific question about your office (please specify in the comments below)

Comments *

Submit

This is a complimentary session for healthcare providers designed to showcase how we work so that you, as a HCP, feel confident in referring your patients to us, knowing that they are safe and will receive adequate (and hopefully great) quality care. The session is geared at helping you resolve any issues YOU have, because the proof is in the results. We realize that receiving bodywork can be stressful, odd or unknown to many patients. So having their HCP refer to someone they actually know and can vouch for, is a great way to get them to trust us and feel safe and comfortable with us. Thank you for trusting us!

Page for Healthcare Providers is here: Healthcare Providers

Problems submitting this form? Call or text 520.858.0350 or email us. Info@millermedicalmassage.com

MillerMedicalMassage.com