CANADA_ ROCKTAPE- Medical Professional Application

Your Name*

First NameLast Name
Your Email*
Phone Number*

Phone Number
Practice Name
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Profession

Certified Athletic TherapistAcupuncturistChiropractorDoctor of OsteopathyKinesiologistMassage TherapistOccupational TherapistPhysiotherapistPedorthistsStudentClinical Exercise PhysiologistExercise physiologistsOther
Medical License No. *
Have you completed a RockTape Education Course?*

FMT with RockTapeNo, but I plan toNo, and I don't plan to
Have you completed a RockTape Education Course?*

FMT with RockTapeOther Legacy RockTape CourseNo, but I plan toNo, and I don't plan to
How did you hear about RockTape?

OnlinePrint AdFriend or ColleaguePatient ReferralOther
By creating a Medical Account with us you agree to not resell on any third party platform follow MSRP.*
Any failure to adhere to these guidelines will result in the immediate cancellation of your account. We reserve the right to pursue legal action against those who infringe upon our policies.
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