The Eye-Q Podcast™ with Dr. Rani Banik
Thank you for your interest in being a guest on The Eye-Q Podcast! Dr. Rani is looking forward to learning more about you and showcasing. your area of expertise! Please complete the guest intake form below as soon as possible. If you have any questions, email us at: info.drbanik@gmail.com. 
Email *
Name *
Email *
Cell Phone Number- Please share your phone number in case there are any technical glitches and we need to reach you the day of the interview. *
Back-Up Number - Please share a back-up phone number in case there are any technical glitches and we need to reach you the day of the interview. *
Please provide a short bio detailing how we can introduce you to our listeners
(less than 150 words)
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Link to Headshot (Weblink, Google Drive link, etc.): (or email to info.drbanik@gmail.com)
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Website *
What is the main value topic that you would like to share with our listeners?
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Please provide 3 bullet points or a list of 3 topics you would like discussed during our episode.
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Have you written a book? 
*If yes, please include the title. Also, at least two weeks in advance of your scheduled interview, please email us a digital version of your book to info.drbanik@gmail.com. Alternatively, you can mail Dr Rani a physical copy to the following address: Rudrani Banik, M.D.  950 Fifth Avenue New York, NY. 10075. 
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By typing my full name here, this will constitute my signature and I understand that The Eye-Q Podcast and Defocus Media will have the right to produce, distribute, record and disseminate the episode as they see fit.*

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