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Facility Name / DBA *

Email (Username) *

Phone *

Password *

Facility Address

Street Address *

City *

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ZIP Code *

Client Information

Client Legal Name *

State of Incorporation or Formation *

Entity Type Select... Corporation LLC Sole Proprietorship

Billing & Legal Notices

Billing Contact Name *

Billing Phone *

Email for Invoices *

Email for Legal Notices *

Coverage

Coverage Type * Traditional locums (hourly) Telehealth (per-consult) Both

I agree that telehealth coverage uses InstantLocums' per-consult pricing as agreed per engagement.

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