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Application Form For Doctors

 

Physicians Join DP

Please fill all the form fields
Currently doctors from all countries can apply ,but if you are a doctor licensed to practice in countries other than the US, it might take longer until a position is available. After your documents have been approved and a position is available we will email you back, so please use a valid email.
First Name :
Last Name :
Gender : Male Female
Birth Date :
Nationality :
State :
Address :
Phone Number :
Email Address:
Practicing Medicine since :
License Number :
Licensed to practice in which states & countries :
Specialty :
Previous & current online consultation experience :
How long would you like to work with us ?
Which days and hours you would like to work with us ?
How much would you like to be paid for each email consult (USD)?
How much would you like to be paid for 20 min live consults (USD) ?
Would you like your profile & picture be viewed on Doctors Pro ? Yes   No
Comments :
Please upload your 1_C.V. , 2_Copy of your License and 3_Picture in the following fields,(maximum file size is 1000 KB ,acceptable file formats are : jpg,jpeg,gif,bmp,png,pdf,rtf,txt,doc,xls, ppt,zip )
Attachment:

Attachment:

Attachment:

Attachment:

Security Code: Security Code
  Click Here for a new code.
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