ChatMedical.AI Caregiver Registration Form - ChatMedical.ai: Global Search, Local Care | The Future of Medical Consultation

Introduction

Welcome to ChatMedical.AI! We’re excited to have you join our community of healthcare professionals and caregivers. Our platform aims to revolutionize healthcare through AI-driven solutions. Please fill out the registration form below to become a part of our network.


Personal Information

  • First Name: ____________________________
  • Last Name: _____________________________
  • Date of Birth: //______
  • Gender: [ ] Male [ ] Female [ ] Other
  • Contact Number: ________________________
  • Email Address: __________________________

Professional Information

  • Caregiver Certification Number: _______________________
  • Issuing Authority: ____________________________
  • Area of Expertise: ______________________________
  • Years of Experience: __________________________
  • Current Affiliation/Agency: ____________________

Credentials

  • Highest Level of Education: ________________________
  • Institution: _________________________________
  • Year of Graduation: ___________________________

Services Interested In Providing

  • Home Care Assistance
  • Telehealth Support
  • Medication Management
  • Content Creation (Blogs, Webinars)
  • Research Collaboration

Availability

  • Preferred Days: [ ] Mon [ ] Tue [ ] Wed [ ] Thu [ ] Fri [ ] Sat [ ] Sun
  • Preferred Time Slots: _________________________

Additional Information

  • Languages Spoken: ___________________________
  • Any Previous Experience with Telehealth?: [ ] Yes [ ] No
  • LinkedIn Profile: ____________________________

Required Documents

Please attach the following documents:

  • Copy of Caregiver Certification
  • Curriculum Vitae (CV)
  • Proof of Identity (Passport/Driver’s License)
  • Proof of Current Affiliation

Declaration

I hereby declare that all the information provided is accurate and up-to-date. I understand that any false information may result in the termination of my account.

  • Signature: ________________________
  • Date: //______

Please submit the completed form along with the required documents to registration@chatmedical.ai

For any questions or concerns, please contact us at registration@chatmedical.ai

Thank you for your interest in joining ChatMedical.AI. We look forward to working with you to make healthcare better for everyone.

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ChatMedical.AI, an innovator in AI healthcare, is a key subsidiary of UL Cell Therapeutic, a leading medical research firm based in Singapore with significant operations in North America and Asia

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