Medical Provider Application
Medical Provider Information
Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Languages fluently spoken in addition to English
Are you a licensed medical professional?
Yes
No
Emergency contact person
First Name
Last Name
Emergency contact phone number
-
Area Code
Phone Number
Scope of Care
Type of Provider
Please Select
Physician
Physician Assistant
Nurse Practitioner
Registered Nurse
Licensed Practical Nurse
Certified Registered Nurse Anesthetist
Emergency Medical Technician
Respiratory Therapist
Certified Nurse Assistant
Social Worker
Pharmacist
Physical Therapist
Behavioral Health Provider
Dentist
Occupational Therapist
Specialty or Care Area
Please Select
Intensive Care Unit (ICU)
Emergency
Department (ED)
Infectious Disease
Med-Surg
OR or Perioperative unit
Ambulatory
Non-acute (outside hospital) settings
Pediatrics
What type of patient care experience do you have?
Ventilators
Palliative Care
Vasopressor drips
Intubation
Dialysis machines (CRRT or CVVH)
Central lines
Inserting IVs
General medical inpatient care
General medical outpatient care
Labor & Delivery
Medication preparation / hanging drips
Please indicate highest level of patient care
Please Select
I can take patient assignment and document care in EHR
I can assist other providers
Work Status
Please Select
Actively practicing
Not actively practicing, but not retired
Retired
Matching with Need
Please indicate highest number of hours you are able to work in a day
Please Select
4
6
8
12
Are you able to volunteer full-time?
Yes,
No, only part-time
Other Information
Please indicate if you have any pre-existing conditions, especially any with COVID-19 increased risk
Yes
No
Other
Signature
Submit
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