Physician Training Request Physician Training Request Please take a moment to complete this form. Once we receive your information, we will contact you to discuss physician training. Asterisk (*) denotes a Required Field. Physician's Name* First Last Phone Number*Email* Location*Specialty*National Provider Identifier (NPI):*Where did you hear about us?*-- Choose One --YouTubeFacebookWeb SearchScientific ArticleNews ArticleDoctorPrevious PatientFamily / FriendOther / Multiple (Please specify below)Where did you hear about us? (Other / Multiple)Where did you attend medical school?*Are you currently in:* Private Practice (Please specify below) Group Practice (Please specify below) Affiliated with a University (Please specify below) Other / Multiple (Please specify below) What is the name of the organization where you are practicing?*How long have you been in practice?*How many patients do you see per day?*In which conditions are you interested in training?* Alzheimer's Disease / Dementia Brain Injury (Acquired, Anoxic, Traumatic, Etc...) Disc-Related Neck & Back Pain / Sciatica Pain Stroke When would you like to come to the INR PLLC for training?* January February March April May June July August September October November December Please upload your CV.If you are unable to upload your CV, please email it to: INRBoca1@gmail.com as soon as possible.