To get started complete all 4 forms

Non disclosure Agreement

Marketing Executive Agreement

Direct Deposit Form

W9 Form

Which medical field are you in ? Check one
Do you currently have patients that are suffering from chronic wounds?

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.

After submitting this form please complete your $50.00 payment.

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