Complete the Registration to Join

The information requested in the form is needed for us to publish your practice in the Air Doctor app and website.

Email adress *

Clinic Phone

Clinic Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Address Notes

Clinic Working Hours *

Physician License Number *

Languages Spoken *

Years of Experience *

Medical School Name

Short CV Summary *

Consultation Fee *

Please state currency

Preferred Payment Method *

Do You Provide Home Visits

Home Visit Consultation Fee

Please state currency

Website

Comments

Website

Company