Form

Email*

Title*

First Name*

Last Name*

Mobile phone number*

Designation*

Consultation Language*

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

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

Alberta (AB)

British Columbia (BC)

Manitoba (MB)

New Brunswick (NB)

Newfoundland and Labrador (NL)

Northwest Territories (NT)

Nova Scotia (NS)

Nunavut (NU)

Ontario (ON)

Prince Edward Island (PE)

Quebec (QC)

Saskatchewan (SK)

Yukon (YT)

How many years have you been practicing medicine?*

Do you have experience providing virtual care?*

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

When are you available to pick up consultations?*

Select all that apply

Weekday daytime

Weekday evenings

Weekends

Overnight

Weekly Consult Capacity (hours)*

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

Please check this box if someone referred you to Maple