EvexiPEL Provider Application

Practice Development Specialist*
District Sales Leader*

PRACTICE INFORMATION

Practice Address*
If none put N/A
Is this clinic currently practicing hormone pellet therapy?*
Have they attended Pellet Therapy Training before?*
Practice Logo
No File Chosen
File uploads may not work on some mobile devices.
jpeg, ai, or eps file format
Does this practice want to be listed on the "Find a Provider" website?

PRACTICE CRITICAL CONTACTS

Practice Manager Admin*
This person will receive patient leads.
Marketing Manager*
This is where leads will be delivered.
Invoicing Contact*
Practice Owner/Signator*
Practice Owner/Signator

PRIMARY PROVIDER INFORMATION

Is this practitioner the Supervising Physician for this practice?*
Primary Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Primary Provider Dea Expiration date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX, WV
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*

OVERSEEING PHYSICIAN

Overseeing Physician Name*
ex: MD, DO
Please list the state and number eg: TX BR549
Medical License Expiration*
DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, pellets cannot be shipped..

Additional Practitioners

1 Do you have additional Practitioners to add?*

2nd PROVIDER INFORMATION

2 Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
2 Provider DEA Expiration Date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX, WV
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*
2 Is this Providers Collaborating Physician the same as the Primary Providers Collaborating Physician?*

2nd OVERSEEING PHYSICIAN

2 Overseeing Physician Name*
ex: MD, DO
DOB
Please list the state and number eg: TX BR549
2 Medical License Expiration*
2 DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, the pharmacy will not ship pellets.

Additional Practitioners

2 Do you have additional Practitioners to add?*

3rd PROVIDER INFORMATION

3 Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
3 Provider DEA expiration date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX WV,
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*
Is this Providers Collaborating Physician the same as the Primary Providers Collaborating Physician?*

3rd OVERSEEING PHYSICIAN

3 Overseeing Physician Name*
ex: MD, DO
DOB
Please list the state and number eg: TX BR549
3 Medical License Expiration*
3 DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, the pharmacy will not ship pellets.

Additional Practitioners

3 Do you have additional Practitioners to add?*

4th PROVIDER INFORMATION

4 Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
4 Provider DEA expiration date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX, WV
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*
Is this Providers Collaborating Physician the same as the Primary Providers Collaborating Physician?*

4th OVERSEEING PHYSICIAN

4 Overseeing Physician Name*
ex: MD, DO
DOB
Please list the state and number eg: TX BR549
4 Medical License Expiration*
4 DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, the pharmacy will not ship pellets.

Additional Practitioners

4 Do you have additional Practitioners to add?*

5th PROVIDER INFORMATION

5 Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
5 provider DEA expiration date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX, WV,
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*
Is this Providers Collaborating Physician the same as the Primary Providers Collaborating Physician?*

5th OVERSEEING PHYSICIAN

5 Overseeing Physician Name*
ex: MD, DO
DOB
Please list the state and number eg: TX BR549
5 Medical License Expiration*
5 DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, the pharmacy will not ship pellets.

Additional Practitioners

5 Do you have additional Practitioners to add?*

6th PROVIDER INFORMATION

6 Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
6 Provider DEA expiration date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX, WV,
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*
Is this Providers Collaborating Physician the same as the Primary Providers Collaborating Physician?*

6th OVERSEEING PHYSICIAN

6 Overseeing Physician Name*
ex: MD, DO
DOB
Please list the state and number eg: TX BR549
6 Medical License Expiration*
6 DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, the pharmacy will not ship pellets.

Additional Practitioners

6 Do you have additional Practitioners to add?*

7th PROVIDER INFORMATION

7 Provider Name*
ex: MD, DO, PA, FNP, NMD
DOB*
Please list the state and number eg: TX BR549
Medical License Expiration*
Medical License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
7 Provider DEA expiration date*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
Practitioner Headshot Photo
No File Chosen
File uploads may not work on some mobile devices.
Does your state require you to have a Collaborating Physician?*
States Include: AL, AK, CA, DC, GA, LA, HI, IL, KS, KY, MS, NE, NJ, ND, OH, OK, RI, PR, SC, TN, TX, WV,
Please provide a few sentences about this providers biography. This information will be used on the EvexiPEL Provider Locator site
Does this practitioner currently perform pellet procedures?*
Is this Providers Collaborating Physician the same as the Primary Providers Collaborating Physician?*

7th OVERSEEING PHYSICIAN

7 Overseeing Physician Name*
ex: MD, DO
DOB
Please list the state and number eg: TX BR549
7 Medical License Expiration*
7 DEA Expiration*
DEA License Certificate*
No File Chosen
File uploads may not work on some mobile devices.
Is the DEA address the same as the practice address where pellets will be stored?*
If this address does not match the practice address, the pharmacy will not ship pellets.

Office Staff

Please fill information for all office staff that will need access to the MyEvexias portal.

Staff Name
MyEvexias Access Level
Check all that apply
2 Staff Name
MyEvexias Access Level
Check all that apply
3 Staff Name
MyEvexias Access Level
Check all that apply
4 Staff Name
MyEvexias Access Level
Check all that apply
5 Staff Name
MyEvexias Access Level
Check all that apply
6 Staff Name
MyEvexias Access Level
Check all that apply
7 Staff Name
MyEvexias Access Level
Check all that apply
8 Staff Name
MyEvexias Access Level
Check all that apply
9 Staff Name
MyEvexias Access Level
Check all that apply
10 Staff Name
MyEvexias Access Level
Check all that apply

EvexiPEL Training Registration

Please enter all the practitioners and staff that will be attending in-person training. If you are enrolling in online training only, please select the appropriate "online only" option in the Training Dates dropdown menu.

Training Details

Attending Integrative Solutions Training? (extra fee)

Please note that if you select "No Training Needed" as an option, we will evaluate where you received your training from and determine if that is adequate to proceed.

Training Attendee Information

Attendee Name*
Which training course are you registering for:*
Please select the meals you will be participating in*
Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
Attending Integrative Solutions Training?
1 Do you have additional attendees to register?*

2nd Attendee Information

2 Attendee Name*
2 Which training course are you registering for:*
2 Please select the meals you will be participating in*
2 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
2 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
2 Attending Integrative Solutions Training?
2 Do you have additional attendees to register?*

3rd Attendee Information

3 Attendee Name*
3 Which training course are you registering for:*
3 Please select the meals you will be participating in*
3 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
3 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
3 Attending Integrative Solutions Training?
3 Do you have additional attendees to register?*

4th Attendee Information

4 Attendee Name*
4 Which training course are you registering for:*
4 Please select the meals you will be participating in*
4 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
4 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
4 Attending Integrative Solutions Training?
4 Do you have additional attendees to register?*

5th Attendee Information

5 Attendee Name*
5 Which training course are you registering for:*
5 Please select the meals you will be participating in*
5 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
5 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
5 Attending Integrative Solutions Training?
5 Do you have additional attendees to register?*

6th Attendee Information

6 Attendee Name*
6 Which training course are you registering for:*
6 Please select the meals you will be participating in*
6 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
6 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
6 Do you want to get pelleted during training?*
*Available only to providers without access to the procedure in their office
6 Attending Integrative Solutions Training?
6 Do you have additional attendees to register?*

7th Attendee Information

7 Attendee Name*
7 Which training course are you registering for:*
7 Please select the meals you will be participating in*
7 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
7 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
7 Attending Integrative Solutions Training?
7 Do you have additional attendees to register?*

8th Attendee Information

8 Attendee Name*
8 Which training course are you registering for:*
8 Please select the meals you will be participating in*
8 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
8 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
8 Attending Integrative Solutions Training?
8 Do you have additional attendees to register?*

9th Attendee Information

9 Attendee Name*
9 Which training course are you registering for:*
9 Please select the meals you will be participating in*
9 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
9 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
9 Attending Integrative Solutions Training?
9 Do you have additional attendees to register?*

10th Attendee Information

10 Attendee Name*
10 Which training course are you registering for:*
10 Please select the meals you will be participating in*
10 Will you have your own on-site transportation?*
Select "No" if you would like to take the shuttle between locations during training
10 For Practitioners who do NOT have anyone in their clinic that can pellet them, do you want to get pellets at training?*
*Available only to providers without access to the procedure in their office
10 Attending Integrative Solutions Training?
10 Do you have additional attendees to register?*

Please contact your Practice Development Specialist to add additional training attendees

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