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* - GEMB Patients has been acquired by US Tele-Medicine

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1. Enter Company Membership information:

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Name of Practice*

Address*

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Main Number*

Main Url

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2. Personal Information

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What best describes your entity?*

Other or

Do you function in more than one state?*

Do you operate a physical clinic?*

Do you operate satellite facilities?*

Do you offer critical care?*

Do you have an ER?*

Do you require additional Family or General Practice Care providers to support your operations?*

Do you currently have a telemedicine department?*

Number of MD's on staff*

Are you interested in transferring chronic care patients for US tele-Medicine for management?*

How did you hear of US Tele-Medicine?*



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