Physician Partnership Form

Let’s co-create root-cause solutions for the patients we both care about.

Thank you for your interest in collaborating with Jena Salisbury, MS, CNS and Innate Clinical Nutrition. Please complete this form to help us understand your clinic, patient population, and how we can best support your goals with:

  • Educational webinars for your patient base
  • Licensed use of our signature functional programs
  • Custom protocol and program development (including integration of in-office modalities or medications)

We’ll follow up to schedule a discovery call once we review your submission.

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Email *
Clinic & Contact Info
Your name (first + last) *
Practice or clinic name *
Role/title *
Required
If you checked 'other' above, please specify.
Phone number
Clinic website and/or Instagram handle *
Clinic location (city + state) *
Primary patient demographics (check all that apply) *
Required
If you checked 'other' above, please specify.
Approximate monthly patient volume *
Do you currently offer any of the following? (check all that apply) *
Required
How Would You Like to Collaborate?
What offerings are you most interested in? (check all that apply) *
Required
Which Innate Clinical Nutrition program(s) interest you? (check all that apply) *
Required
Would you like to use your own in-office modalities or pharmaceuticals within the program delivery?
 *
If yes to above, please list what you’d like to integrate (e.g., GLP-1s, peptides, ozone, PEMF, etc.): *
Final Details
What outcomes or goals are most important to your clinic? (check up to 3) *
Required
If you checked 'other' above, please specify.
Anything else you'd like us to know?
Submit
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