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INFLUENCER
Francine Gaillour, MD, MBA, CPE, PCC
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1. I understand that completing this form does not guarantee that this information will appear on thephysicianproject.com. The information I provided will be reviewed, and I will be notified if my entry has been accepted or not.
2. If my entry is approved, I am allowing The Physician Project to display all of the information I have provided in this form except my email on thephysicianproject.com.
3. I understand that I will be able to view, edit, and update my information if it is added to thephysicianproject.com.
4. I understand that I can request the removal of my information from thephysicianproject.com using the CONTACT US form at https://www.thephysicianproject.com/terms
5. I understand that if the information I provided in this form becomes outdated (as determined by The Physician Project) it may be removed from thephysicianproject.com without notice.
6. I understand that there is no fee or compensation for adding my information to thephysicianproject.com, and there is no fee for editing my information on this website.
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Checking this box and completing this form means you understand and agree to the following.
1. I understand that completing this form does not guarantee that this information will appear on thephysicianproject.com. The information I provided will be reviewed, and I will be notified if my entry has been accepted or not.
2. If my entry is approved, I am allowing The Physician Project to display all of the information I have provided in this form except my email on thephysicianproject.com.
3. I understand that I will be able to view, edit, and update my information if it is added to thephysicianproject.com.
4. I understand that I can request the removal of my information from thephysicianproject.com using the CONTACT US form at https://www.thephysicianproject.com/terms
5. I understand that if the information I provided in this form becomes outdated (as determined by The Physician Project) it may be removed from thephysicianproject.com without notice.
6. I understand that there is no fee or compensation for adding my information to thephysicianproject.com, and there is no fee for editing my information on this website.
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Influencer Description (max 1500 char)
May we COPY & UPLOAD an image from your URL?
Yes, I permit The Physician Project to borrow my image and apply it to my influencer page.
No, I'd prefer that a stock image be used.
URL of Influencer Image (page where image is found)
Checking this box and completing this form means you understand and agree to the following.
1. I understand that completing this form does not guarantee that this information will appear on thephysicianproject.com. The information I provided will be reviewed, and I will be notified if my entry has been accepted or not.
2. If my entry is approved, I am allowing The Physician Project to display all of the information I have provided in this form except my email on thephysicianproject.com.
3. I understand that I will be able to view, edit, and update my information if it is added to thephysicianproject.com.
4. I understand that I can request the removal of my information from thephysicianproject.com using the CONTACT US form at https://www.thephysicianproject.com/terms
5. I understand that if the information I provided in this form becomes outdated (as determined by The Physician Project) it may be removed from thephysicianproject.com without notice.
6. I understand that there is no fee or compensation for adding my information to thephysicianproject.com, and there is no fee for editing my information on this website.
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View your listings
00188-01
[post:listing_name]
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Your Influencer ID is 00188
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