WATERMARK HEALTH
Specialist Referral Interest Form
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Specialist Referral Interest Form
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Form Entry
Interested in becoming a Specialist Referral for Watermark Health
First Name
First Name is required.
Last Name
Last Name is required.
Email
Email address is not valid
Email is required.
Mobile Phone
Mobile Phone is required.
Birthdate
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Birthdate cannot be a future date.
Gender
Male
Female
Some Quick Questions!
Are you at a private practice?
No
Yes
Are you at a private practice? is required.
Are you an owner/partner at your practice?
No
Yes
What is your speciality?
Dermatology
Physical Therapy
Podiatry
Orthopedic
Counseling
Women's Health
Dental
Ophthalmology
ENT
Other
What is your speciality? is required.
What is your license type?
Physician (D.O.)
Physician (M.D.)
Provider (NP)
Provider (PA)
Radiology
Other
Dentist
LPC
What is your license type? is required.
Other License Type
How are you hoping to partner together?
See Patients at my practice
See patients at Watermark/CityBridge Urgent Care
Participate at satellite clinics
Advise/Consult as Needed
Other
How are you hoping to partner together? is required.
Do you have a church home?
No
Yes
Where?
Don't Have One and/or Currently Looking
Watermark Community Church (Dallas)
Watermark Community Church (S. Dallas)
All Saints Dallas
Chase Oaks Church
Citizens Church
City Church International
CityBridge Community Church
Dallas Bible Church
Eastside Community Church
Gateway Church (Dallas)
Northway Church
Northwest Bible Church
Prestonwood Baptist
The Parks
The Village Church
Watermark Fort Worth
That's it!
Someone from our team will reach out to you as soon as we can! We look forward to hopefully working together soon!
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