Provider Signup : CareClix

Learn how CareClix can bring telehealth to your business. Complete the form below and we'll be in touch soon.

Do you belong to a medical society?

Yes
No

Medical Society *

What would you like to name your online clinic?

ie: hopkins1800 (minimum of 4 characters, no spaces or special characters)

What is your physical Clinic Address

Address Line 1

Address Line 2

City

State

Zip Code

What is the main point of contact's info *

Phone Number

Email *

How many physicians would you like to have in your clinic?

Physician Details

Physician Name *

First

Last

DOB *

Email *

Phone Number

Admin

Name *

First

Last

DOB *

Email *

Phone Number

Terms & Conditions

Agreement to terms & conditions

Information Accuracy

To my knowledge, information provided is accurate