Healthcare Professionals Registration

Healthcare
Professional's
Registration

Register Here

We are building the global network of African healthcare professionals including Physicians, Surgeons, Clinicians, Nurses, Pharmacists, Dentists, Radiologists, all healthcare workers and medical students as part of the effort to transform healthcare for Africa. Join our network and benefit from making your healthcare services available to our vast database of beneficiaries while expanding your customer base. Your registration information will be kept secure and private.

Step 1 of 5 - Personal Data

20%

Name (As shown on your National Identification)*
Title First Middle Last Suffix
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Preferred Mailing Address:
- Select All
- Office
- Home
Practitioner’s Preferred E-mail address:*
Cell Phone Number:*
Home Phone Number:
Country of Origin:*
Select country
Do you speak a language other than English with sufficient fluency to treat patients who speak only that language?
- Yes
- No
If yes, specify languages:

From:
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
Institution Name:
Type of Program/Specialty:
Completed Training:
- Yes
- No
If no, expected completion date:
Date Format: MM slash DD slash YYYY
If not successfully completed, explain:

From:
Date Format: MM slash DD slash YYYY
To:
Date Format: MM slash DD slash YYYY
Institution Name:
Appointment Held/Position:

Primary Specialty
Board Name:
Board Specialty:
License Number:
Original Certificate Date:
Date Format: MM slash DD slash YYYY
Expiration Date:
Date Format: MM slash DD slash YYYY
Certificate Pending
- Yes
- No
Secondary Specialty:
Board Name:
Board Specialty:
License Number:
Original Certificate Date:
Date Format: MM slash DD slash YYYY
Expiration Date:
Date Format: MM slash DD slash YYYY
Certificate Pending
- Yes
- No
Additional Specialty:
Board Name:
Board Specialty:
License Number:
Original Certificate Date:
Date Format: MM slash DD slash YYYY
Expiration Date:
Date Format: MM slash DD slash YYYY
Certificate Pending
- Yes
- No
Do you have additional specialty?
- Yes
- No
Note
If not certified, please state your intent for certification and describe the status of your efforts and eligibility, including scheduled date of exam, past failures of written or oral exams, if any.
Notes

EMAIL

hello@diaspocare.com

ADDRESS

USA

2147 University Avenue West, Suite 105,
St. Paul, MN 55114
+1 612 4449876

KENYA

P.O. Box 1139 – 00621, Village Market, Nairobi
+254 742 532981
+254 756 503006

GHANA

P. O. Box 1091 DK, Accra Ghana
+233 54 937 3718

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