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Become a Provider

Application 2 – Application

Become a Provider

Application

Name(Required)
If different from mobile
Business Address(Required)
Drop files here or
Accepted file types: jpg, png, pdf, Max. file size: 250 MB.
    Do you work under another contracted primary SHAPE practitioner?
    How did you hear about us?
    If this question does not apply, type "None"
    Confirmation(Required)
    After completing and submitting your application, please check your inbox. You will receive an email confirmation with a request to email our CoFounder, Linda Frisch, with several options that you would be available to chat. She will reply by return email and choose one of your options that fits her schedule as well.
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    SHAPE ReClaimed Central Office
    510 Baxter Road, Suite 6
    Chesterfield, MO 63017

    636-484-8444
    customerservice@shapereclaimed.com

    Copyright 2023 SHAPE ReClaimed. All Rights Reserved. 

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