Join the Foundation for Wellness Professionals

Please complete the following form in full in order to sign up.

Note: You must be an active client of David Singer Enterprises or the Neurologic Relief Center to be a member of the Foundation for Wellness Professionals.

All fields are required.

This information will be publicly displayed. Please make sure all information is accurate and properly formatted.

Doctor's First Name:
Doctor's Last Name:
Profession:
Clinic Name:

Spell out completely, no abbreviations.
Address:
City:
State:
Zip:
Phone:

E.g.: xxx-xxx-xxxx
Fax:

E.g.: xxx-xxx-xxxx
Email Address:
Website Address:
Referred by:
 

Choose a login (required)

For editing your profile in the event that your address or phone numbers change.
Username:
Password:

Minimum 8 characters, must have at least one number.
Retype password: