Intake Form - Medical Staff

Personal Information:

First Name:

Last Name:

Email:

Phone No.:

Street Address:

City:

State:

ZIP Code:

Country:

Professional Information:

Current Occupation:

Professional Title:

Years of Experience:

Licenses and Certifications:

License/Certification Name:

Traditional Medical Licenses Certifications:

Specialty Medical Certifications:

Nursing Licenses Certifications:

Holistic Alternative Medicine Certifications:

Mental Health Licenses Certifications:

Diagnostic Imaging Therapy Certifications:

Telemedicine Digital Health Certifications:

Rehabilitation Physical Occupational Therapy Certifications:

Emergency Critical Care Certifications:

Surgical Medical Laboratory Assistant Certifications:

Holistic Therapies Wellness Certifications:

Pharmaceutical Biotech Certifications:

Public Health Administrative Certifications:

NP (Nurse Practitioner) License:

License/Certification Number:

Issuing State/Country:

Expiry Date:

List all States/Countries where you are certified:

Are you certified to administer IV treatments?

Yes

Are you certified to administer joint injections?

Yes

Document Upload:

Specialties:

Medical Specialties:

Holistic and Wellness Specialties:

Mental Health and Emotional Wellness Professionals:

Advanced Practitioners and Specialized Care Providers:

Specialty care offices:

Years of Experience:

Additional Specialties:

Years of Experience:

Treatment Information:

Are you interested in providing telehealth services?

Yes

Are you interested in performing in-person treatments?

Yes

Would you prefer performing treatments at a servicing location on our platform?

Yes

Are you willing to travel to patients' homes to administer treatments?

Yes

Availability:

Are you looking for full-time or part-time opportunities?

Yes

What is your preferred work schedule?

Are you open to flexible scheduling based on patient needs?

Yes

Are you interested in working in multiple states/countries?

Yes

Training and Education:

Have you received training for stem cell and regenerative treatments?

Yes

Are you interested in receiving additional training provided by MD Global Care?

Yes

Referral Information:

How did you hear about MD Global Care?

Are you currently sending referrals to attorneys or clinics?

Yes

Types of facilities or products you refer:

Professional Affiliations:

Are you currently associated with any other clinics or healthcare facilities?

Yes

Services and Capabilities:

Are you capable of administering multiple types of treatments?

Yes

Please list the treatments:

Are you interested in providing telehealth consultations?

Yes

Are you willing to work at a servicing location registered on our platform?

Yes

Additional Information:

Do you have any additional comments or questions for MD Global Care?

Consent Agreement:

By submitting this form, I agree to the terms and conditions of collaborating with MD Global Care.