Request a Medical Director

📌 Before You Begin

Thank you for choosing Wholesome Collaborations. This form will help us understand your business and state-specific needs so we can identify an appropriate match for you. You may be asked to sign in or create an account when you submit, so we can track your request.

To begin: a $99 intake deposit is required.

The intake deposit is fully refundable if you cancel your request before our matching process begins. Once physician outreach is initiated or an introduction is made, the deposit becomes non-refundable to cover administrative and vetting costs.
Remaining onboarding balance due only after match approval

Onboarding fees if matched:

First state: $300 less deposit
Additional state, same NP/business/physician: $125
Additional state, new NP/business/physician: $300

Important: Some states have CPOM laws that may require an MSO structure with a licensed physician.

Practice & Contact

Today's Date *

Practice Name *

Owner/Contact Person *

Title/Role *

Credentials *

RN/LVNEMT/ParamedicNP/PAOther (Please specify below)

Email Address *

Phone/Mobile *

Practice Address

Address Line 1 *

Address Line 2

City *

State *

ZipCode *

Additional Services

Do You Require Any of the Following? (check all that apply)

Additional Comments or Preferences

Please upload ResumeDrag & drop a file or browse

Confirmation & Agreement

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. *

Wholesome Collaborations Business Service Agreement Acknowledgement

By proceeding, you agree to the Wholesome Collaborations Business Service Agreement and Non-Circumvention Policy.

You agree not to bypass Wholesome Collaborations by directly engaging with physicians introduced through our network
You agree not to introduce other clinicians or businesses to those physicians outside of our platform
These terms apply during your engagement and for 24 months after termination
Violations may result in remedies as outlined in the agreement

I agree to the terms above and Wholesome Collaborations Business Service Agreement *

Intake Deposit (Will be applied towards Onboarding Fee)

After completing payment, please return to this form and finish your intake submission. We're unable to begin processing your request without the deposit.

$99 initial deposit to initiate search. A final matching balance of $201 will be invoiced upon director approval.

All submissions reviewed within one business day.

Medical Director Request Form

Practice & Contact

Practice Address

Practice Details

Match Preferences

Additional Services

Confirmation & Agreement