Clinical Personnel Interest Form
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
We appreciate all the help!
Sign in to Google to save your progress. Learn more
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? *
Are you interested in a supervisor role (i.e. supervising students, teaching, etc) *
Are you currently licensed in the state of Michigan? *
Do you have any questions and concerns?
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy