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1. Your Name

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2. Practice or Company Name

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3. What is practice location address?

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4. What is your email address?

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5. What is your practice website address?

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6. What is your practice phone number?

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7. Please click the choice that best describes your practice:

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8. Do you have more than one location?

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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?

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10. Are there multiple physicians at your facility/practice?

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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.

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12. Please list your specialties/services

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13. Please provide the description of your practice/facility:

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14. Have you provided us with:
*Please email the logo and pricing form to support@fmma.org

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15. Are there any pending or known regulatory actions, lawsuits, or other legal actions against you or your company?

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