Are you a medical professional interested in joining our network of outstanding doctors, nurses, massage therapists, dentists, chiropractors, dermatologists, etc...? Please complete and submit the following form and our client relations department will contact you.

Your name :
Your email :
Field of Medicine :
Phone: () ext.
Fax  :   ()
Best Person to speak to :
**Wellness Fairs are booked on a first come, first served basis and the most heavily attended are often confirmed in a matter of minutes. It is to your advantage to be reachable by your office to receive notification
Addresses of all Manhattan Offices:


For what insurance plans are you in-network?

Preferred area of Manhattan

Preferred time for a Wellness Fair: 10am - 12pm
. 2pm - 4pm
Others

Special Instructions or Considerations:



Name of Signatory:




PARK AVENUE CORPORATE HEALTH
TEL:212-593-1117 580 PARK AVENUE NEW YORK, NY 10021 FAX:212-593-0969
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