My Home Therapist

Registration Page

*Required fields

* First Name
* Last Name
* Username
* Password
* Confirm Password
* Email Address
* Profession Occupational Therapy Physical Therapy Speech Therapy
* PRC License     Valid Until
* School
* Year Graduated
* Post Graduate Degree or
Courses Attended
* Area Serviced for home Therapy
* City Serviced for home Therapy

* please select Area Serviced first.

* Time of Service
06:00 - 08:00 08:00 - 10:00 10:00 - 12:00
12:00 - 14:00 14:00 - 16:00 16:00 - 18:00
* Short description about yourself (aspects, characteristics, and/or accomplistments that will "wow" potential clients)
* Contact Number
* Upload Picture
* Image Captcha Type the characters you see in this image.

Type the characters:

Letters are not case sensitive

Notice:
The data will be transferred to a website that will contain a directory of therapists willing to do home therapy. The aim of this site is to provide a place where patients and physicians can conveniently look for a therapist based on certain requirements (e.g., place of practice). At this time, there are no charges for this service. Thank you.

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