Healthcare Worker Sign Up
We are currently accepting registrations for licensed healthcare workers that can volunteer to help those in need via our telehealth platform. It is easy to use, and if you have even 15 minutes a day - or even a week - you can make a difference.
Help us stop the spread and save critical medical supplies in the war against the COVID-19 pandemic.If you will be able to help now or in the near future, please fill out the information below and our team will reach out on next steps.
We are working around the clock to launch this initiative and will be posting more public-facing content in the coming days at
Zip / Postal Code
Your valid 10 digit NPI (national provider identifier)
Must be a credentialed physician (MD or DO), Nurse Practitioner, or PhD in the event of mental health care)
M.D. / D.O.
PhD (Non-medical: Mental Health /Counselor)
Anything else you'd like to share about yourself.
Never submit passwords through Google Forms.
This form was created inside of liveclinic.