Join our Physician Network

📌Before You Begin:

Thank you for your interest in joining our network of collaborating physicians and medical directors. This form will help align you with practitioners based on licensure, specialty, clinical preferences, and compensation expectations.

Our network includes practitioners at various stages of growth, from early-stage launches to established practices. Please select only the collaboration tiers and add-ons that reflect your current preferences — this ensures thoughtful, well-aligned introductions.

All collaborations are mutually agreed upon, and you'll always have the opportunity to connect directly with the practitioner prior to moving forward.

Personal & Contact

Today's Date *

First Name *

Last Name *

Email *

Mobile Phone *

Preferred method of contact *

EmailPhone CallTextAny

Credentials & Specialty

NPI Number *

Primary Specialty *

Other Specialties *

Primary Practice State *

Primary Practice City *

Which specialties/specialty are you open to/comfortable supervising? *

Collaboration Preferences

Licensing

Address (used in agreement)

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Malpractice & Additional Info

Do you have personal or employer malpractice insurance coverage? *

Personal CoverageEmployer CoverageBothNone

To be added to the NP's coverage as additional insured. Some carriers require comparable personal coverage.

How did you hear about us? *

Please add any additional information

Resume (PDF or Word)Drag & drop a file or browse

Public Profile

Headshot (shown on your public profile)

Upload headshotJPG or PNG, square works best. Max 5 MB.

Short Bio (shown on your public profile)

Availability

Agreement

Wholesome Collaborations Physician Participation Agreement

By submitting this form, you acknowledge and agree to our Physician Participation Agreement and Non-Circumvention Policy, understanding that if matched with a provider/client, you may not bypass or attempt to negotiate separate terms outside of the Wholesome Collaborations' network.

I have read and agree to the Wholesome Collaborations Physician Participation Agreement *