Enrollment

Please complete the form below to enroll in the Telemedicine program.

Based on your information, we will create your Telemedicine page.

Please enable JavaScript in your browser to complete this form.
Name of business
Doing Business As if different from Business Name
Name
Person responsible for business
Email
business email
Business Phone Number
Address
Business Address
Bu signing the form below I agree to the Terms and Conditions of telemedicine.
Clear Signature
website address of the business
for funds deposit
Bank Account Routing Number for funds deposit
Bank Account Number for funds to deposit
Select the Date
Payment for the selected plan
Payment for setting up the telemedicine

Thank you

Terms and Conditions-telemedicine-pdfDownload

Telemedicine plans fees-pdfDownload