Onboarding Form - Telemedicine - PRAXES Emergency Specialists

Main Contact Information

Full Name *

First

Last

Email *

Main Company Information

Same as Main Contact Information?

Yes
No

Company Name

Country

Billing Information

Name *

First

Last

Email *

PO Number

Main Operations Contact Information

This is the person in your company that PRAXES will reach out to for any business renewals, ongoing operational concerns, and send incident reports to when your vessel calls in for Telemedicine assistance.

Name *

First

Last

Position/Job Title

Phone *

Email *

Medical Training

Yes
No
Limited

Receive Incident Reports?

Yes

Would you like to add a Backup Operations Contact?

Yes

Name of Backup Operations Contact

First

Last

Position/Job Title of Backup Operations Contact

Phone of Backup Operation Contact

Email of Backup Operation Contact

Medical Training of Backup Operation Contact

Yes
No
Limited

Receive Incident Reports?

Yes

Service Information

Industry *

Total Number of Locations or Vessels *

Location/Vessel Name/Project Name *

Location Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Type of Vessel

Telemedicine Coverage Start Date *

Telemedicine Coverage End Date

Ongoing Service (no end date specified)?

Yes

Primary Phone # (normally the main Satellite Phone) *

Backup Phone Number

Access to (select all that apply):

Access to Medevac?

Yes
No

Approximate Time to Nearest Emergency Department

Medical Kit

Medical Kit Available On-Site *

Yes
No

Please upload an Excel, Word, or PDF copy of your medical kit at your location (OPTIONAL, but preferred)

Click or drag a file to this area to upload.

Caller Information

In this section, we ask you to specify who will be using the Telemedicine Service as Callers. You can add up to 4 callers. We need to gather these details, to understand the skill/training of the personnel who will be calling us.

Name of Caller #1 (This is the main/primary caller) *

First

Last

Role/Job Title of Caller #1

Medical Role of Caller #1

(First Aider, Registered Nurse, Primary Care Paramedic, etc.)

Primary Language of Caller #1 *

Email of Caller #1 *

Is there a 2nd Caller you would like to add?

Yes

Name of Caller #2

First

Last

Role/Job Title of Caller #2

Medical Role of Caller #2

(First Aider, Registered Nurse, Primary Care Paramedic, etc.)

Primary Language of Caller #2

Email of Caller #2

Vessel Photo

It is optional, but providing a photo of your vessel offers some context for the PRAXES Physicians when answering Telemedicine calls.

Upload a photo of your vessel (OPTIONAL, but preferred):

Click or drag a file to this area to upload.

Special Instructions

Are there any special notes that you'd like to tell us? (Optional)

Terms and Conditions

Terms of Use *

Check this box to confirm you have read and agree with PRAXES Terms of Use.

View a copy of our Terms on our website here: https://praxes.ca/terms

Onboarding Form – Telemedicine

Main Contact Information

Main Company Information

Billing Information

Main Operations Contact Information

Service Information

Medical Kit

Caller Information

Vessel Photo

Special Instructions

Terms and Conditions