Schar Welcome Package Form
Please complete the fields below so we can best serve you and your clients.
First & Last Name: *
Your answer
Email address: *
Your answer
Phone Number *
Your answer
Tell us a little about your practice:
Practice Name: *
Your answer
Type of Practice: *
Required
Medical Specialty: *
Required
On average how many patients/clients do you see per month on a gluten-free diet? *
Your answer
On average how many of these patients are newly diagnosed? *
Your answer
How many kits would you like per quarter? *
Your answer
Where should we send the Welcome Packages?
Company Name *
Your answer
Contact Name *
Your answer
Address 1 *
Your answer
Address 2 *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
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