SOTTOPELLE, INC. QUESTIONNAIRE

This questionnaire is for a natural person (the “Practitioner”) and/or a medical practice (the “Entity”) either of
which becomes an affiliate upon entering into an agreement with SOTTOPELLE, INC.
Before you or your medical practice becomes an affiliate, we must ask for information that will allow us to
understand you and your medical practice. Our diligence process require that we obtain examples of your driver's license DEA licenses.

Accordingly, SottoPelle, Inc.* (“SottoPelle,” “we” or “us”), conducts both initial due diligence on prospective affiliates as well as ongoing diligence through periodic updates of affiliate information.
Please complete the following questionnaire. When complete, please send this original, signed questionnaire, along with the related certification and other documentation to:

SottoPelle, Inc.
Attn: CarolannTutera
8580 E Shea Blvd; Suite 140
Scottsdale, AZ 85260
Telephone: (480) 874 – 1515 ext 229
Facsimile: (480) 941 – 1518
Email: CarolAnn@sphrt.com

If you would like to download the pdf and print and fax to us: 480-941-1518, please Click Here.

Please retain a copy of this questionnaire and the related certifications for your records.
Notes:
1. SottoPelle shall protect and keep private the information it has requested. However, in certain
circumstances, SottoPelle may be compelled, from time to time, to disclose this information to legal,
regulatory or governmental authorities.
2. In the future, SottoPelle’s procedures may require affiliate information to be updated when
considered necessary by SottoPelle.

All Fields are Required

Full Legal Name:
Office address (no P.O. boxes) :		and mailing address (if different):
City:
State:
Zip:
Telephone:		Fax:
Email:
Date of Birth:
Do you have a current and valid license to practice medicine:
Are you board certified:
Doctor Initials:
Please list which board and date of certification:
Please list each state in which you have a valid license:
Please provide a current and valid copy of your medical license for each state and/or country.
Do you currently have medical malpractice insurance:
Please provide a valid copy of your medical malpractice insurance certificate and related documents.
Do you have a current DEA license
DEA Number:
Date license obtained:
Expiration date:
Please provide a valid copy of your DEA license.
Do you accept insurance:
Do you accept PPO:
Do you accept HMO:
Are you a Medicare provider:
Do you currently practice or have you ever practiced any method of hormone replacement therapy:
Do you currently practice or have you ever practiced using pellets:
If yes, who taught you:
How long have you been using them:
Please describe the type of hormone replacement therapy you have practiced in the past or are currently practicing:
DOCUMENT CHECKLIST: Please provide the following with this Questionnaire: 1. Photocopy of a valid medical license in each state such license is valid. 2. Photocopy of a valid DEA license.