Name

First Name

Last Name

Email Address

Year of Graduation

Class Number

Are you currently licensed and practicing?

Name and Address of your practice

i.e. Acupuncture Clinic of Central Florida 100 Wellness Road Health Town, Longevity, 99999

Your Business Website

Average number of patients seen per week

Would you like your practice information made public on our online practitioner database?

7100 Lake Ellenor Dr. Orlando. FL 32809 | Tel: 407.888.8689 | www.FCIMclinic.com

Florida College of Integrative Medicine | Orlando School of Acupuncture and Herbal Medicine

Alumni Survey