Primary Spine Care Qualification Application Contact Us Name * First Last * Last Address * Phone Email * State & License #'s Are there Malpractice/Licensure actions against your license: Yes No If yes, describe date, action and circumstances briefly and understand we will be verifying all below with your licensure board. I have taken the following (or the equivalent) course(s). Please check all that apply. To qualify, you must have taken any of the 4 above. Attendance will be verified Primary Spine Care 1 Primary Spine Care 2 Primary Spine Care 3 Primary Spine Care 4 (live only) Primary Spine Care 5 Primary Spine Care 6 Please Initial Today's Date Submit If you are human, leave this field blank.