Practitioner Listing Registration & Forum Setup

Please complete the below form and submit your registration. We will then forward your details onto Dr Natasha's Website Technician for processing. Soon after this, your Business Profile will be listed on the official GAPS Practitioner Listing at Dr Natasha Campbell-McBride's website and at the GAPS Diet Australia website. Please keep your created username and password safe. These will be used to grant you access to Dr Natasha's Practitioner Forum. Please allow a week or two for your details to be collected along with other newly Certified GAPS Practitioner profiles before your profile is listed and Practitioner Forum Account activated.

*IMPORTANT: Your registration for the above must be re-submitted annually on the eve of your training anniversary to advise us that you are still in practice. At any time you wish to change or update your business profile, please re-submit this form and advise that you are renewing your listing or updating your profile.

This form is to be completed by “Trained & Certified GAPS Practitioners” ONLY If you are not certified, your registration will not be authorised and your details will not be listed.

YOUR GAPS CLINIC BUSINESS PROFILE

Your profile details below will be added to the Practitioner Listing when you are ready to practice
Practitioner Registration Status *

Practitioner Registration Status I am a new Certified GAPS Practitioner & wish to register I wish to submit my annual registration to remain on the Practitioner Listing I wish to update my details Other Other
Date GAPS Training Course Completed Date GAPS Training Course Completed * / DD / MM YYYY

IMPORTANT Remember to renew your registration each year on this date to remain on the Practitioner Listing
Name Name * First Last
Practice/Business Name *
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Business Phone Number: *

(area code) + number
LEAVE NO SPACES BETWEEN NUMBERS & NO BRACKETS
Business Fax Number

(area code) + number
LEAVE NO SPACES BETWEEN NUMBERS & NO BRACKETS
Business Email *
Web Site
OLD ADDRESS: If you are updating your renewal with a new address above, please complete your old address below so that we can find you in our Practitioner Listing and delete your old content. If this is not supplied, your new address can not be added. (otherwise please ignore this step) OLD ADDRESS: If you are updating your renewal with a new address above, please complete your old address below so that we can find you in our Practitioner Listing and delete your old content. If this is not supplied, your new address can not be added. (otherwise please ignore this step)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
PROFESSIONAL

Your professional qualifications and area of special interest
Professional Qualifications: *

ie: Naturopath, Nutritionist, Nutrition Consultant
Areas of Special Interest *

ie: Specialising in women's health, autism, heart health, autoimmune disorders or
Simply state if you do not have a specialty
YOUR CLINIC/PRACTICE STATUS

Activate your ONLINE Business Profile on Dr Natasha's Worldwide Practitioner Listing and GAPS Diet Australia's Practitioner Listing
Are you in active practice and ready to receive GAPS clients now? *

Are you in active practice and ready to receive GAPS clients now? YES, please add my profile to the Practitioner Listing. NO, I am not quite ready yet but I still wish to register so that I may access the online Practitioner forum. N/A I have already been added to the listing thank you. Please remove me from the listing.

If YES, you will be added to both Online Practitioner Listings.

If NO, we can add your profile later when you are ready to accept clients by submitting this form again.
CREATE YOUR USER NAME AND PASSWORD BELOW TO ACCESS THE PRACTITIONER FORUM

THIS SECTION MUST BE COMPLETED IF YOU ARE A NEWLY CERTIFIED GAPS PRACTITIONER. If you already have access and are just renewing your registraion, there is no need to complete this section
Please Create your USERNAME for the Practitioner Forum - NO SYMBOLS, FULL STOPS OR DASHES
Must be between 8 and 12 characters. Currently Entered: 0 characters.
Must have at least 1 alpha and 1 numeric
NO SYMBOLS, FULL STOPS OR DASHES
Please Create your PASSWORD for the Practitioner Forum - NO SYMBOLS, FULL STOPS OR DASHES
Must be between 8 and 12 characters. Currently Entered: 0 characters.
Must have at least 1 alpha and 1 numeric
NO SYMBOLS, FULL STOPS OR DASHES
Your account access to the forum may take a few days before it is activated. If you are ready to receive GAPS Clients now, your business profile will be added to the Worldwide Listing on Dr Natasha's website, at the same time.

Practitioner Listing Registration & Forum Setup

Practitioner Listing Registration & Forum Setup

YOUR GAPS CLINIC BUSINESS PROFILE

PROFESSIONAL

YOUR CLINIC/PRACTICE STATUS

CREATE YOUR USER NAME AND PASSWORD BELOW TO ACCESS THE PRACTITIONER FORUM