Practice Information Worksheet

Instructions: Use this worksheet to gather all your practice and business details before completing the Remote Medical Director onboarding form. Fill in each field below -- having this information ready will make the onboarding process quick and smooth.

Business Identity

Practice / Business Name

Legal Entity Type

LLC Corporation S-Corp Sole Proprietorship Partnership Other: _______________

State of Incorporation

Business Formation Date

EIN / Tax ID Number

Contact & Location

Business Address -- Street

City

State

ZIP Code

Mailing Address (if different from above)

City

State

ZIP Code

Phone Number

Fax Number

Email Address

Website

Owner / Principal Contact

Owner / Principal Full Name

Title

Phone

Practice Details

Practice Type

Med Spa Aesthetics Clinic Wellness Center Dermatology Office Day Spa Other: _______________

NPI Number (if applicable)

Number of Locations

Number of Practitioners