PROVIDER REGISTRATION

TELL US A LITTLE ABOUT YOURSELF/YOUR PRACTICE
( * Required )
    

* First Name + Mid. Initial

  
(ex:First, Mid)

Last Name

  

* Facility/Clinic/Organization Name

  

Credentials

  

* Mailing Address 1

  

* Gender

  

* City

  

* State or Province

  

* Zip

  

* Time Zone

  

* Office Phone
Example: (800) 123-4567

 
Office Fax
Example: (800) 123-4567
 
Home Phone
  
     
* Private Information
* Your Email Account
  
YES! show e-mail on my page
Web site USE ENTIRE URL
http://www.yourcompany.com
  
YES! show web Site on my page
ABOUT YOUR PRACTICE
Title
 
Type of Facility
  
Number of Professional Staff
  
Years in Practice
  
 
SERVICES YOU OFFER
 Rates for services
 
Services
 Check this Box if you want to offer this service
iConferencing
If box is checked enter your fee
Chat Room
If box is checked enter your fee
Encrypted eMail
If box is checked enter your fee
Office Visits
If box is checked enter your fee
Telephone
If box is checked enter your fee
Rates for services are set strictly by the Health Provider. VirtualHealthServices.com does not collect fees from any sessions.
PAYMENT(S) YOU ACCEPT FOR YOUR SERVICES
( ie: Medicaid, Medicare, Most Insurances, Sliding Scale, Set Cash fee, Visa, MC, Paypal Account )
1 2 3 4
5 6 7 8
DEGREE(S)
Use abbreviation only.
1 2 3
4 5 6
LICENSE(S) & CERTIFICATION(S)
Please write out the full license/certification.
1 2 3
4 5 6
SPECIALITIES / AREAS OF EMPHASIS / COMPETENCY
Emergency Psychiatry/Psychology Nursing
Internal Medicine Orthopedics Education
Oncology Urology Training
Dermatology Ear/Nose/Throat Social Services
Pediatrics Tropical Medicine Administration
General Surgery Mental Health Special Diseases & Disorders
Family Medicine Gerontology Radiology
Obstetrics/Gynecology Cardiology Pharmacy
Ophthalmology/Optometry Podiatry Laboratory
AREAS MOST OFTEN WORKED IN
( ie: children, adults, aging, couples, groups, testing, medications )
1 2 3
4 5 6
THEORETICAL ORIENTATION
 ( ie: brief therapy, existential, communications, cognitive, eclectic )
1 2 3
PROFESSIONAL ASSOCIATION MEMBERSHIPS
1 2 3
4 5 6
LANGUAGES SPOKEN OTHER THAN ENGLISH
 ( ie: Spanish, French, Japanese )
1 2 3 4
ADDITIONAL INFORMATION
 A description of yourself, your online practice or any other information you would like the potential client to know.
 
Virtual Health ServicesAccount Information
 (Directory Name ) ( ie: Account Name and Password.) ( Email User Name and Password )
* Enter a directory_Name you would like to use here ( no spaces or symbols )
* You will have a web site address on this site which will be referenced like this:
http://www.virtualhealthservices.com/sites/directory_Name
(4 - 20 characters only)
*Enter USER NAME to be used to logon to VirtualHealthServices.com (4 - 20 characters only)
*Enter PASSWORD to be used to logon to VirtualHealthServices.com (4 - 20 characters only)
*Enter PASSWORD to Confirm (4 - 20 characters only)
Membership Information
*Please select a type of membership
  1 month for $0.00
  Free Listing: This listing will list your practice including name, and phone number on the World Wide Web. There is no access to the virtual tools to provide online services.
 
  1 month for $19.95
  Secure Chat, Email service: With this membership you will have access to provide secure online chat, and secure email services to clients. This membership gives you full access to state of the art tools to provide real time therapy online. You also have access to your own virtual Office were you can create payment buttons to receive easy payment, update services that you offer, have access to hundreds of providers in a secure forum, easy design of your personal web page, and full control of all service tools. Your name will be listed on Google.com with a direct link to your web page and a press release will be sent to your local papers to let people know that you are providing online services. LetsTalkCounseling.com takes no commission per session; you charge clients what ever your fees are. Membership Discounts: (Pay six months at a time and receive 1 Free month) (Pay twelve months at a time and receive 2 Free Months)
 
  1 month for $39.95
  Secure Chat, Secure Email Service, and secure Audio/Visual connection: With this membership you will have access to provide secure online chat, secure email, and real time Audio/Visual services to clients. This membership gives you full access to all state of the art tools to provide real time therapy online. Were you can actually see and hear your client. You also have access to your own virtual Office were you can create payment buttons to receive easy payment, update services that you offer, have access to hundreds of providers in a secure forum, easy design of your personal web page, and full control of all service tools. Your name will be listed on Google.com with a direct link to your web page, premier front page listing on LetsTalkCounseling.com and a press release will be sent to your local papers to let people know that you are providing online services. (Pay six months at a time and receive 1 Free month) (Pay twelve months at a time and receive 2 Free Months)
 
Billing Information
Payment Type
I authorize Virtual Health Services,Inc. to deduct my Monthly service fee on the first of every Month when billing begins from my checking account or credit card account. I understand that I control my payments, and if at any time I decide to discontinue this service, I will notify Virtual Health Services, Inc. in writing.
Card Number
Expire Date
Billing Zip Code
VirtualHealthServices.com strives to create the most complete virtual office on the net.
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* Please note: Virtual Health Services does not provide and is not responsible for any direct Health Care Services. Virtual Health Services is a technology portal created to facilitate communication between health care providers and their patients.