Provider Signup 2 - Online Telemedicine

Title

First Name

Middle Name

Last Name

Your Email

Prospective patients may use this email to contact you

Personal Email

This will not be visible to patients. Our team use this number to contact you regarding your profile.

Your Phone Number

Prospective patients may use this number to contact you

Personal Phone #

This will not be visible to patients. Our team use this number to contact you regarding your profile.

Write a few paragraphs about yourself. This will be displayed on your profile for prospective patients to get to know you better.

Which state(s) are you licensed in? Use the + icon to add additional states

State Name	License #	Expiry Month	Expiry Year

What is your primary office address? This will be used for verification purposes

Address

City

State

Zip Code

Do you accept insurance?

Yes

Which insurance providers do you accept?

Out of network costs

Please specify your per-session costs for those patients who are out-of-network or uninsured

Minimum Cost

Maximum Cost

Please list your education history. Click the + icon to add more rows

School Name	Degree/Field of Study

Do you have any board memberships/affiliations?

Yes

List all your board affiliations. Use the + button to add additional rows

Affiliation/Membership Name

Do you have any awards?

Yes

List all your awards. Use the + button to add additional rows

Award Name	Year

Do you have any certifications?

Yes

List all your certifications. Use the + button to add additional rows

Certification Name	Year