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VTMEDI - ONPLAY Client Intake Form
Connection to Another Healthcare
Client Information
Name
*
MR
MS
MD
DO
ND
PA
NP
RN
DNP
PHARMD
Prefix
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Business Profile
Business Name
*
Business Type
Please Select
Medical
Medical Spa
Wellness Center
Healthcare Professional
Website
Tax ID / EIN
*
NPI Number
*
NPI Number
*
Reseller’s Permit Number
Does your business have a reseller’s license
Yes
No
Not Sure
Upload Reseller’s Certificate
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload Proof of Business or Professional License
Browse Files
Drag and drop files here
Choose a file
Optional at this stage. Clinics may upload a business permit; individual providers may upload a license or valid ID. Required later to complete your application.
Cancel
of
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by someone? Let us know!
Optional—but filling this in may give you priority approval if applicable!
Contact Person
First Name
Last Name
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