Modo Bio registration page for medical doctors Step 1 of 8 - About You 12% First Name:* Last Name:* Email:* Phone Number*State:*Please Select oneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code:* Date of Birth* MM slash DD slash YYYY What is your role?*Select all that are appropriate Medical Doctor (MD) Doctor of Osteopathic Medicine (DO) Advanced Practice Registered Nurse (APRN) Other OtherYears of Experience* QualificationsClick + to add multiple State LicensesLicense State* Add RemoveLicense Number* Add RemoveLicense Expiration* Add RemoveDEA NumberAdd if applicable. Add RemoveNPI NumberAdd if applicable. Add RemoveAdditional CertificationsSeperate certitifcations by a comma. You may enter up to 5. Write below exactly how you would like your name to be displayed.Example: Dr. Gary Visser, MD, FAAFP Add Your EducationClick "Add" to add multiple Education/Degrees. College/University Name Degree Year of Graduation Medical School Year of Graduation Residency Years Fellowship (If done.) Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. What areas of medicine interest you?*You may select up to 10 Allergy/Immunology Dermatology Men's Health Neurology Oncology Ophthalmology Pediatrics Preventative Medicine Psychiatry Sports Medicine Urgent Care Urology Weight Loss Women's Health Other Other SpecialtiesAge GroupsSelect all that are appropriate.Toddlers/Preschools (0-6)Children (6 to 13)Adolescents (14 to 19)AdultsElders (65+) Do you speak any additional languages?Select all that are appropriate Albanian Arabic Armenian Bengali Bulgarian Chinese Creole Croatian Czech Dutch Farsi French German Greek Gujarati Hebrew Hindi Hungarian Italian Japanese Khmer Korean Laotion Lithuanian Mongolian Persian Polish Portuguese Punjabi Romanian Russian Serbian Spanish Swahili Swedish Tagalog Taiwanese Turkish Ukranian Urdu Uyghur Vietnamese Other Other Languages spokenSpeciality PopulationsSelect all that are appropriate Actors Bariatric Beginners Bodybuilders Brides-to-be Cancer Survivors Dancers Disabled Law Enforcement LQBTQ+ Men Middle Aged Military Models Overweight/Obese Peri/Post-Menopausal Post-Rehab Pre/Post-Natal Rehab Runners Seniors Student Athletes Women Youth Other Other Speciality Populations Do you offer virtual training?* Yes No Do you want to offer virtual visits on Modo Bio's platform?* Yes No Do you want to recieve referrals for in-person clients from Modo Bio?* Yes No What is your physical location for training? Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Provider BioWhy did you get into this field? What is your general philosophy when it comes to health and fitness? Describe your ideal client. Anything else you would like potential clients to know. Website Instagram Facebook Twitter Tiktok Initial EvaluationPlease enter your standard ratePrice $$* Time XX min* One on One SessionPlease enter your standard ratePrice $$* Time XX min* Partner SessionPlease enter your standard ratePrice $$* Time XX min* Small Group SessionPlease enter your standard ratePrice $$* Time XX min* Virtual SessionPlease enter your standard ratePrice $$* Time XX min* Sliding Scale?* Yes No
