Clinical Personnel Interest Form

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Thank you for your interest in providing their services free of charge to clinic patients. Detroit VITALS is a 100% FREE virtual healthcare clinic where we provide the highest quality of affordable virtual medical care for every patient. This form is eligible for clinical personnel (Doctors, SW, RN, PA, PT etc) along with PCPs (FM and IM trained Doc's and APP's (Advanced Practice Practitioners)). Please fill the information below and if you have any questions or concerns, email detroitvitals@gmail.com.
We appreciate all the help!

Email *

First name? *

Last name? *

What is the best way to contact you? (phone number, email, etc.) *

What is your profession? *

What are your credentials? (i.e. MD, DO, DP, NP, PA, RN, MA, DPT, etc) *

Do you want to help with the planning committee/clinic policies? *

Yes

Maybe

Are you interested in a supervisor role (i.e. supervising students, teaching, etc) *

Yes

Maybe

Other:

Are you currently licensed in the state of Michigan? *

Yes

Do you have any questions and concerns?

Submit

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