QSPACES Provider Listing

Premium Provider Profile

Please fill out this form for a Premium profile on the QSPACES app. This form is intended for providers to add more information about themselves and to grow their practice. The QSPACES app works in all states on iOS and Android platforms.
Basic Information
Name *

First Name Middle Name Last Name, Title
Pronouns
Email Address *
for QSPACES to contact you, not for patients
Practice Categories *
no more than 3. example: primary care, massage therapist, etc.
Tags to describe you / your practice

Accepts Insurance Fat Positive Kink Positive LGBTQ+ Identified Person of Color Sex Worker Competent Sliding Scale Payments Trans Competent Trauma Informed
Practice Description and Images

Add your practice and personal information into the box or upload a word document. The description can have links, bold and italic text, bullets, etc. Additional images can be embedded by providing a link to an image that already exists online (right or 2 finger click on an image to "Copy Image Address"). The banner image will be at the top of your listing and it will crop to fit. We suggest using Canva as an easy way to build a custom header (headshot with text or image of practice).
Banner Image

Browse Files
approx. 5 x 2 inch banner Cancel of
Description of Provider and Practice (or upload a document below with links, bold, bullets, italics, etc.)
links can be included and additional images can be embedded by providing a link to an image (i.e. a link to a headshot on a LinkedIn or website)
Description Files

Browse Files

Cancel of
Additional Information

Mailing Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Hours
example: M-F 8am - 5pm
Phone

Area Code Phone Number
Email Address
for patients
Website Link
Facebook Link
Twitter Link
Instagram Link
Payment

Premium Profiles will be active for 1 year. We offer a sliding scale payment to help with individual and infrequent practices.

My Products

Good! $ 18.00

Better! $ 29.00

Best! $ 40.00

Payment Method

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Should be Empty:

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Premium Provider Profile

Basic Information

Practice Description and Images

Additional Information

Payment