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Thirty Madison - Urgent Care
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* Indicates required question
Name
*
Your answer
Email address
*
Your answer
Phone number (optional)
Your answer
Board Certification/Specialty
*
Your answer
Do you have Telemedicine experience?
*
Yes
No
Which conditions are you comfortable treating? Please select all that apply.
*
Stomach issues
UTI
Eye infections
Back pain
Cold & flu
Headaches / migraines
Rashes / hives
Other skin issues like poison ivy / bug bites
Yeast infections / BV
Pregnancy concerns
Allergies
Required
Approximately how many hours per week would you want to donate over the next month? Please note that hours are non-binding, extremely flexible, and completely up to you.
*
1-5
6-10
11+
Other:
Required
Please list your state licenses
*
Your answer
How did you hear about us (please mention the name of a Thirty Madison employee if relevant, so that we can thank them for the referral)? (optional)
Your answer
Questions? Comments?
Your answer
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