Welcome to ShiftMed!
Please complete the following questions to help your dedicated Customer Success Team learn more about your facility.
Facility Name
*
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Name
*
First and Last
Title
Email
*
example@example.com
Who will need access to the ShiftMed Portal? (Select Add New Contact for additional users)
*
Please enter Primary and Secondary Contacts for Day, Night, and Weekend.
*
What are your shift structures? (Ex: CNA 7-3, 3-11, 11-7)
*
Please list names of Nursing Supervisors who will have permission to sign out ShiftMed Healthcare Professionals. (Note: They will NOT have portal access)
*
Select the Resource Types for this location:
*
RN
LPN
CNA
STNA
RT
GNA
Other
If Other, please indicate the resource type:
Enter additional resource types.
Credentials
*
Who can we contact to discuss credential requirements? (Please list name and email)
*
Who is your AP Billing Contact?
*
Name
AP Billing Email
*
Please list email address.
AP Billing Phone Number
*
Please list phone number.
AP Billing: Is this a local contact or corporate contact?
*
Local
Corporate
Any additional AP contacts?
Please list name and email.
Do you require an Orientation Shift? and/or additional forms? If yes, please explain below.
Please describe orientation.
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