Receptor-Based Essential Certificate Form

First Name*
Last Name*
Name on Certificate*
First Middle Last
Please fill out your name as you'd like it to be listed on your certificate. Middle name/initial is optional If you add Dr. or your credentials, they will be removed from the certificate.
What program are you requesting a certificate for?*
- Concussion/mTBI
- ReceptorBased Essentials
- Pain Reset
- Human Performance
- Neurochemistry and Nutrition
Please choose an option below*
- Email
- Mail to physical address - $35 fee
Email

If you choose to email your certificate, you will receive it in two formats. Print ready and digital-ready.
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you choose to have it mailed, a $35 fee will be invoiced to your email or charged to a card on file. Please allow 6-8 weeks to process and ship.
Pain Reset | ReceptorBased Essential Scholars
If you have completed this series and would like to be spotlighted on social media, please fill out the portion below. This includes, you have taken all 50 hours of education, completed and passed your exam, and spoke with a faculty advisor.
Upload your personal headshot
Max. file size: 128 MB.
Feel free to upload your headshot; we want to share your accomplishments on social media.
What is your clinic website?

Please include your website; if we can link that on social media, we will.

BRAIN DISSECTION WITH PROF. CARRICK