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.After submitting this form please complete your $50.00 payment.(Required) Agree to the terms and conditions EmailThis field is for validation purposes and should be left unchanged.
