Apply for Practice Launch by Amber

1. Contact and notice details

Required fields must be completed before the email draft is generated. If a required detail is not available now, use the matching "I cannot provide..." checkbox.

Legal full name Preferred name Phone Email Instagram / TikTok / website City / area Business / entity name, if any Best contact method

2. License, status and insurance

Provider type New York license active License number License expiration date NPI, if applicable Professional liability insurance

Current employer / practice status Restrictions, conflicts or existing obligations I cannot provide license number or expiration now; I understand it may be required before approval. I cannot provide current employer / practice status now.

3. Procedure scope and certification

Years in aesthetics Realistic monthly appointment capacity

Neuromodulators / tox Dermal fillers Threads PRP / PRF Microneedling IV / wellness GLP-1 / weight-loss injection services Esthetic / non-medical services I cannot define procedure scope yet

Procedures you want to offer Training / certifications already completed Certification needs I cannot provide detailed procedure information now. I cannot provide certification details now.

4. Schedule and location readiness

Ready to work at 1729 East 12 Street, 3rd Floor Earliest realistic start date Preferred days Preferred hours Can use up to 15 approved room days / month Room exclusivity interest after first 90 days

I cannot provide start date, preferred days or preferred hours now.

5. Clients and demand

Approximate active clients Clients you can bring in month one Main demand source Need Amber clients / leads

Client base notes I cannot provide client count or demand details now.

Do not paste client names, phone numbers, dates of birth, medical information, full client lists or screenshots of client conversations.

6. Products and inventory

Products / brands you expect to use

Will you bring your own products? Need Amber ordering route? Source / lot / storage docs ready Understand product costs are separate

Product compliance notes I cannot provide product brands or product compliance details now.

7. Communication, CRM and sales support

Current client communication process I cannot provide communication workflow details now.

Select communication, CRM, lead and sales support modules in Optional services below. Off-site client communication through Amber may be beta, limited, modified or unavailable depending on the approved system and privacy requirements.

8. Optional services

Clinical readiness and procedures

Procedure certification Additional training / retraining sessions Special procedure or scope review

Products, inventory and process support

Product ordering through Amber route with handling/admin fees Inventory / procurement coordination upgrade Custom SOP or process support Custom forms / compliance document setup, subject to legal review Not sure - discuss available add-ons

Additional services are subject to separate approval, availability, scope, pricing and written confirmation.

9. Documents and file readiness

Select provider credential files only. A clear photo or screenshot is acceptable for preliminary review. You may cover or redact information you do not want to show at this stage, but original or unredacted documents may be required later during contract signing, secure onboarding or credential verification. Do not upload patient records, client lists, SSNs, passwords, card data, or documents containing PHI. On this static page, selected file names are included in the summary; actual document transfer should happen through an approved secure upload link or CRM workflow.

Credential document readiness

Professional license Choose No file selected Photo, screenshot or PDF of your professional license or official license verification. You may cover non-required personal details for preliminary review. Malpractice / liability insurance Choose No file selected Photo, screenshot or PDF of a certificate of insurance, declarations page or active policy proof. Training certificates Choose No file selected Photos, screenshots or PDFs of procedure training certificates, course completion proof or clinical sign-off documents. Resume / professional bio Choose No file selected Resume, CV or short provider bio. PDF, DOC or DOCX is preferred for text documents. Business / entity docs Choose No file selected If applying through an entity: formation proof, EIN confirmation, DBA, operating agreement excerpt or other business verification. Redact tax-sensitive fields if needed for preliminary review. Product source / storage docs Choose No file selected Photos, screenshots or PDFs showing supplier/source, lot, storage, expiration or product documentation, if relevant.

Preliminary photos are acceptable. Cover or redact information you do not want to show at this stage. Original or unredacted documents may still be requested before agreement signing, secure onboarding or final approval.

10. Privacy Policy and Terms

Review the separate Privacy Policy and Terms before opening the email draft. They consolidate the privacy, communication, document handling and candidate acknowledgement items for this preliminary provider application.

Final approval, payment link, secure document upload, credential verification and contract signing are handled separately.

Apply for Practice Launch

Privacy and data handling

What this request covers