My Virtual Physician Application

1
What is your Name?* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
In what city and state do you physically reside?ONLY ANSWER THIS IF YOU LIVE IN THE US
5
What is your primary specialty* This field is required.
Internal Medicine
OBGYN
FAMILY MEDICINE
PEDIATRICS
Psychiatry
Dermatology
MED-PEDS
Other
6
Select the states in which you are licensed* This field is required.
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
7
Which of the following types of consults would you be willing to do* This field is required.
Longitudinal primary care (you become the patient's PCP)
"Sick visits/Acute visits" (Including knowing when to refer pt to ER)
Mental Health consults(diagnosis)
Mental Health consults (refilling prescriptions, diagnosis already established)
Consults related to gynecological issues(AUB, Menopause, STDs, Low Sex drive etc etc)
Consults related to obstetrical issues
Consults related to postpartum issues (patients with questions about the postpartum period)
Consults related to contraception(esp non hormonal methods such as the CAYA diaphragm)
Consults related to certification for Medical Cannabis Card
Consults related to Emotional Support Animals
Consults related to Medical accommodations for standardized tests
Consults related to patients interested in genetic testing(primary immune deficiency and neurocognitive disorders)
Asynchronous Visits
8
Upload your CV or resume here* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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9
Upload your state licenses here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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10
Upload NPDB report here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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11
Upload your Headshot here
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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12
Upload your one-paragraph "Bio" here (in word document)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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13
I have completely opted out of Medicare* This field is required.
YESNO
14
On at least 2 days of the week, would you be able to give us availability in the middle of the day (12-2pm EST)
YESNO
15
Number of 15m slots you can provide if we hire you
8 or less
9-16
17-24
25-32
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Fridays
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Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
8 or less
Row 0, Column 0
9-16
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17-24
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25-32
Row 0, Column 3
8 or less
Row 1, Column 0
9-16
Row 1, Column 1
17-24
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25-32
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8 or less
Row 2, Column 0
9-16
Row 2, Column 1
17-24
Row 2, Column 2
25-32
Row 2, Column 3
8 or less
Row 3, Column 0
9-16
Row 3, Column 1
17-24
Row 3, Column 2
25-32
Row 3, Column 3
8 or less
Row 4, Column 0
9-16
Row 4, Column 1
17-24
Row 4, Column 2
25-32
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16
Signature* This field is required.I hereby declare that the information submitted is accurate to the best of my knowledge
Clear
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