To get started complete all 4 forms Non disclosure Agreement Click here Marketing Executive Agreement Click here Direct Deposit Form Click here W9 Form Click here Full Name(Required) Address(Required) Phone(Required)Email(Required) Which medical field are you in ? Check one Nursing Home Assistant Living Home Healthcare Other Do you currently have patients that are suffering from chronic wounds? Yes No I acknowledge and agree that the information provided on this form is accurate to the best of my knowledge. I understand that submitting this form does not establish a patient-provider relationship. By checking this box, I consent to the processing of my data in accordance with the privacy policy of Affa Mobile Wound Care. Your one-time payment of $50.00 is non refundable, this payment is for patient tracking and onboarding training that will be held on Tuesday and Saturdays.(Required) Agree to the terms and conditions PhoneThis field is for validation purposes and should be left unchanged.
