Become Prescriber

If you are an exercise professional, we encourage you to fill out the application below to become a MyoLIFE exercise prescriber. We will respond to your application within 24 hours.

 

MyoLKIFE Prescriber Application Form

Your First Name (required)

Your Last Name (required)

Your Email (required)

Phone Number-Include Area Code

Location (City and State)

Date of Birth

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Degrees and Certifications:

Areas of Specialization:

Recent Work Experience:

Hobbies and Interests:

An Interesting Fact About Yourself:

Your Profile Statement (this will be your bio on the MyoLIFE website):

Upload a Photo

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