Member Pricing Form Question Title 1. Your Name OK Question Title 2. Practice or Company Name OK Question Title 3. What is practice location address? OK Question Title 4. What is your email address? OK Question Title 5. What is your practice website address? OK Question Title 6. What is your practice phone number? OK Question Title 7. Please click the choice that best describes your practice: Direct Primary Care (Membership Model) Primary Care (Fee for Service ) Specialist Facility/ASC Imaging Lab Pharmacy Other, please explain Comments / Description OK Question Title 8. Do you have more than one location? Yes No OK Question Title 9. If yes, do these locations have the same pricing and services? *If locations have different pricing and services, a separate form and pricing template will be needed for each location? Yes No Please provide details OK Question Title 10. Are there multiple physicians at your facility/practice? Yes No OK Question Title 11. If yes, do these physicians need to be listed as sellers at your facility/practice? **Individual physicians must be a MEMBER to be listed on the site. Yes No Comments OK Question Title 12. Please list your specialties/services OK Question Title 13. Please provide the description of your practice/facility: OK Question Title 14. Have you provided us with:*Please email the logo and pricing form to support@fmma.org A high resolution version of your logo? The Pricing Template Form? Other (please specify) OK Question Title 15. Are there any pending or known regulatory actions, lawsuits, or other legal actions against you or your company? Yes No If yes, please provide details OK DONE