Licensed Healthcare Providers

New 2020 Form

Do you have an unrestricted state license to practice in the state where you live?

Yes

No

Do you have a laptop computer and are you comfortable using it?

Yes

No

Can you work at least one day per month (usually on a Saturday)?

Yes

No

Do you have any corrective or malpractice history in your record?

Yes

No

Are you able to evaluate a wide range of ages and demographics?

Yes

No

Name *

First

Last *

Last

Email *

Phone

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