Provider Enrolment - Step 1 of 5Service DescriptionType of provider *ClinicSupport Service ProviderSelect the type of providerSupport Service Provider Category *LaboratoryDiagnostic CenterSelect the support service provider categoryClinic SpecialtiesOncologyCardio Vascular SurgeryProvider Name *Enter your Solo Practice name, your clinic name or support service provider nameMedical Company ID *Enter your Company IDLicense Number *Enter your medical license numberUpload Medical Company Certification File *Include a certification issued by your local goverment to demonstrate your company has permission to give medical services.Website / URLEnter your personal/company website addressNextLegal representative informationName *Enter your nameLastnameDate of birth *Enter your date of birthEmail *EmailConfirm EmailEnter a valid email addressPhone *Enter a phone number with international format. (area code) number. Country *CubaHaitiDominican RepublicPuerto Rico (US)JamaicaTrinidad and TobagoGuadeloupe (France)Martinique (France)BahamasBarbadosSaint LuciaCuracao (Kingdom of the Netherlands)United States Virgin Islands (US)Aruba (Kingdom of the Netherlands)GrenadaSaint Vincent and the GrenadinesAntigua and BarbudaDominicaCayman Islands (UK)Saint Kitts and NevisSint Maarten (Kingdom of the Netherlands)Saint Martin (France)Turks and Caicos Islands (UK)British Virgin Islands (UK)Caribbean Netherlands (Kingdom of the Netherlands)Anguilla (UK)Saint Barthelemy (France)Montserrat (UK)Select your CountryAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeFill in your addressNextPractice LocationCountry *CubaHaitiDominican RepublicPuerto Rico (US)JamaicaTrinidad and TobagoGuadeloupe (France)Martinique (France)BahamasBarbadosSaint LuciaCuracao (Kingdom of the Netherlands)United States Virgin Islands (US)Aruba (Kingdom of the Netherlands)GrenadaSaint Vincent and the GrenadinesAntigua and BarbudaDominicaCayman Islands (UK)Saint Kitts and NevisSint Maarten (Kingdom of the Netherlands)Saint Martin (France)Turks and Caicos Islands (UK)British Virgin Islands (UK)Caribbean Netherlands (Kingdom of the Netherlands)Anguilla (UK)Saint Barthelemy (France)Montserrat (UK)Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNextTeam membersIn this section you must upload an excel file containing your team conformation. For every member it is required to include: Full Name, Department (ex. Family Medicine), Role (Administrator or Primary Account Owner or healthcare provider), medical license id, phone number, email and the supported service type (video consultations, chat consultation, on site consultations).Upload Team Members *only excel files admittedTerms and PoliciesCheckboxes *I confirm that the information given in this form is true, complete and accurate.Checkboxes *I have read and agree to the Terms and Policies.WebsiteSubmit
