VirtuCare Membership Form

ABOUT US

VirtuCare Network: Solutions to remove barriers to access healthcare for families.

Our mission: We believe in the power of collaboration. Through the VirtuCare Network, we will provide effective and efficient healthcare services and support for patients and caregivers

HOW IT WORKS

The expectations and benefits of joining the VirtuCare Network: Ethical & Efficient Services and Increased Business Referrals.

Through VirtuCare network, warm referrals and increased business are the outcomes. The expectation is that when you encounter someone who has a need, please refer them to someone within the network to fill that need.

VirtuCare Referral Network is actively seeking partnerships with stakeholders who share our goal of eliminating barriers and enhancing healthcare access for families and their loved ones.

VirtuCare Intake Form
Company Physical Address (Type non brick-and-mortar into address line 1 if you do have a physical location)
Address Line 1
Address Line 2
City
Province/State
Zip/Postal Code
Country
Is your company a for-profit or not-for-profit?
If your company a for-profit, do you offer a subsidized rate or sliding scale for your fees?

Maximum file size: 516MB

Can you provide a copy of a business license (if applicable)?
Can you provide a copy of Business Insurance on an annual basis?
Contact Name
Contact Name
First
Last
Can you provide a Police Clearance with Vulnerable Sector Check if required?
Name and contact number.
Please indicate if the reference is a client or a business.
Name and contact number.
Please indicate if the reference is a client or a business.
Are you affiliated with a professional association?
I agree to review and sign a confidentiality/non-disclosure agreement upon approval.
Declaration:

I, the undersigned, confirm that the information provided in this intake form is true and accurate to the best of my knowledge. I understand that by joining the VirtuCare Referral Network, I am committed to conducting business ethically, serving the best interests of vulnerable populations, and maintaining an independent business relationship with clients. I release and indemnify the VirtuCare Network, including organizers and other businesses, from any legal responsibility that may arise in connection with my business relationship with a client(s).

Thank you for your interest in partnering with VirtuCare Referral Network. We will be in touch. 

Team CarePal Database Option:

Caregivers often encounter challenges in accessing essential resources and support.

Our Goal:

Support caregivers by sending them the resources they need when they need it.

How do we achieve this?

By growing a network and promoting the utilization of the existing support ecosystem. If you offer services or resources that benefit people caring for a loved one with an illness, disability, or aging needs, please click the box below. Team CarePal will be in touch with the next steps.

Yes, I would like to learn more about Team CarePal’s database.