Interest Form
Full Name
*
Organization
*
Email
*
Phone
*
What services do you offer?
*
IV Hydration
Weight loss
Hormone Replacement
Aesthetic Injectables
Medical Spa (non injectables)
Functional Medicine
Primary Care
Psychiatry
Other
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States where telemedicine coverage is needed
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Deleware
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
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Time Zone:
*
Eastern
Central
Mountain
Pacific
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Number of telemedicine visits expected each week (for each state):
*
1-10
10-25
25-50
50+
Are you requesting evening and/or weekend telemedicine coverage?
Yes
Estimated number of visits expected each week during evening hours
*
1-10
10-25
25-50
50+
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Estimated number of visits expected each week during weekends
1-10
10-25
25-50
50+
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List is empty.
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