Modo Bio Doctor Sign-Up

First Name:*

Last Name:*

Email:*

Phone Number*

State:*

Zip Code:*

Date of Birth*

What is your role?*

Select all that are appropriate

Medical Doctor (MD)

Doctor of Osteopathic Medicine (DO)

Advanced Practice Registered Nurse (APRN)

Other

Years of Experience*

Qualifications

Click + to add multiple State Licenses

License State*

License Number*

License Expiration*

DEA Number

Add if applicable.

NPI Number

Add if applicable.

Additional Certifications

Seperate certitifcations by a comma. You may enter up to 5.

Write below exactly how you would like your name to be displayed.

Example: Dr. Gary Visser, MD, FAAFP

Add Your Education

Click "Add" to add multiple Education/Degrees.

College/University Name	Degree	Year of Graduation	Medical School	Year of Graduation	Residency	Years	Fellowship (If done.)	Actions

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What areas of medicine interest you?*

You may select up to 5.

Other Specialties

Age Groups*

Select all that are appropriate.

Toddlers/Preschools (0-6)

Children (6 to 13)

Adolescents (14 to 19)

Adults

Service Location

Do you offer virtual visits?*

Yes

No

Do you want to offer virtual visits on Modo Bio's platform?*

Yes

No

Do you want to recieve referrals for in-person clients from Modo Bio?*

Yes

No

What is your physical location?

Street Address Address Line 2 City State ZIP Code

Provider Bio

Why did you get into medicine? What is your general philosophy when it comes to working with clients? Describe your ideal client. Anything else you would like potential clients to know.

Website

Instagram

Facebook

Twitter

Tiktok

Initial Evaluation

Please enter your standard rate

Price $$*

Time XX min*

One on One Session

Please enter your standard rate

Price $$*

Time XX min*

Virtual Session

Please enter your standard rate

Price $$*

Time XX min*

Sliding Scale?*

Yes

No