AI Wellness Platinum Network & Infinity Interactive Directory – Practitioner Intake Form

Welcome!
Join the AI Wellness Platinum Network to access our Center of Excellence, Longevity Lab, TAP Card, media opportunities, and Infinity Interactive Directory. This form also sets up your automated onboarding, program integration, and payment workflows.

Practitioner Intake

Practitioner Information

Full Name
Full Name
First Name
Last Name
MD, NP, DO, ND, etc.
Address
Address
City
State/Province
Zip/Postal

Licensing & Credentials

Maximum file size: 268.44MB

Consent for License Verification

Membership & Payment

Platinum Network Annual Membership

Platinum Network Annual Membership: $6,500.00

Program & Media Integration

Select Programs Your Work Aligns With
Select Media Opportunities

Practitioner Availability

Preferred Times for Patient Sessions
Consent for Auto-Scheduling / Reminders via App or Voice AI

Consent & Legal Agreements

  • HIPAA / Privacy Consent: Yes / No
  • Telehealth Consent: Yes / No (if virtual sessions offered)
  • Liability Waiver: Participation in center, media, and masterclasses
  • Media & Content Consent: Use of photos, videos, podcasts, and promotional materials
  • Compliance Agreement: Follow AI Wellness protocols, safety, and program guidelines
  • Intellectual Property: Permission to feature logos, images, or branded materials in media and directories
Agree to all above Consent

Content & Collaboration Preferences

Would you like to film content at the Center?
Would you like to host masterclasses?
Would you like to co-lead pilot programs?
Total

Payment