Provider Interest Form

Fill out details about you and your practice — we'll get back to you shortly.

Email *

Please enter a valid email

Title *

Required

First Name *

Required

Last Name *

Required

Mobile phone number *

Required

Practice Type *

Primary Care (e.g. family medicine, walk-in) Specialist / Other

Required

Consultation Language *

Please select which language(s) your are comfortable completing visits on Ogaei in

Required

Additional Languages

Please enter any additional language(s) that you would be comfortable completing visits in

Licensed Jurisdictions *

Please select all the jurisdictions for which you hold an active license

Ontario (ON)

Select at least one

How many years have you been practicing medicine? *

Required

Do you have experience providing virtual care? *

Required

Are you comfortable conducting both video and audio calls when necessary? *

Required

When are you available to pick up consultations? *

Select all that apply

Weekday daytime Weekday evenings Weekends Overnight

Select at least one

Weekly Consult Capacity (hours) *

What is the average hours per week you expect to be able to dedicate to working on Ogaei

Required

Please check this box if someone referred you to Ogaei

Please fill required fields.

Thank you — your submission has been received.