Provider Chat Enrollment Form - Rutgers RWJ Your Health Kiosk

An "*" indicates a required field

Name*

First Last

Mobile Number*

Speciality*

Select all that apply.

If "Other", please specify:*

How many years have you practiced?*

Please provide the full address of your practice, group, or hospital:

Practice, Group, or Hospital Name*

Address*

Street Address City State ZIP Code

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In which County do you practice medicine?*

What languages do you speak fluently or provide translation services for?*

(Select all that apply)

You chose "Other", please specify:*

What insurance types do you accept?*

(Select all that apply)

Are you currently accepting new patients through referrals?*

Please describe your expertise briefly:*

Do you take care of Long COVID patients?*

What are your primary goals for joining Your Health Kiosk?*

(Please select all that apply)

You chose "Other", please specify:*