1. Provider identity
Enter the registered identity we should verify and the public-facing details users
could see if this provider is approved for listing or routing.
Individual clinician
Clinic or practice
Diagnostics or pharmacy
Digital care partner
Onboarding contact name
Onboarding contact email
Onboarding contact phone
Role or title
Registered practice, company, or professional name
Public display name
Website
Main city
Province, state, or region
Country
Public service areas, branches, or virtual coverage
3. Registration and verification
Provide enough information for credential review and safe classification. Do not
include patient names, patient records, or patient-identifiable information.
Professional regulator or register
Select one
Medical, nursing, pharmacy, psychology, allied-health, or facility regulator
South Africa: HPCSA, SANC, SAPC, AHPCSA, or equivalent
United Kingdom: GMC, NMC, HCPC, GPhC, or equivalent
United States: state board, licensing board, facility licence, or equivalent
EU or EEA national professional register
Other national or regional professional register
Not regulated in this market
Other
Registration or licence number
Years in practice
Indemnity or malpractice cover
Select one
Yes
No
Not applicable
Prefer to discuss
Current professional standing
Select one
Active and in good standing
Active with conditions or restrictions
Pending registration
Not applicable
Prefer to discuss
Verification document links
Qualifications, certifications, fellowships, and relevant training
Scope boundaries or services not provided
4. Access model and operations
Help us understand how a user can realistically reach this service, what it costs,
and which next step InsideHer should suggest.
Current new-patient capacity
Select one
Yes
Limited capacity
Waitlist only
No, profile for referral context only
Typical first appointment availability
Booking URL
Public booking phone or WhatsApp
Public booking email
Referral requirement
Select one
No referral required
GP referral preferred
Referral required
Depends on service
First consultation price range
Follow-up price range
Accessibility, facilities, and practical notes
Insurance, medical aid, public-sector, or payment details
5. InsideHer workflow fit
Tell us which InsideHer workflows the provider is prepared to support: directory
listing, care routing, clinic referral links, patient summaries, pilots, or content review.
Patient-generated InsideHer summaries
Select one
Yes, patients can bring or show summaries
Yes, through a secure portal only
Maybe, needs workflow review
No
Preferred summary review method
Select one
Patient shows on phone
Patient prints and brings
Secure portal upload
Email after patient consent
Do not send before visit
Prefer to discuss
Pilot or referral capacity
Implementation timeline
Select one
Ready now
This quarter
Next 6 months
Exploring only
Existing systems, workflow, or integration requirements
Why is this provider a strong InsideHer fit?
6. Safety, privacy, and governance
These answers help us avoid unsafe routing, unclear data handling, unmanaged conflicts,
or misleading patient expectations.
Privacy policy URL
Data protection framework
Select one
GDPR
HIPAA
POPIA
Multiple privacy frameworks
Other national privacy framework
Not sure
Emergency care availability
Select one
Emergency care available onsite
Urgent triage available, emergency referral required
No emergency care, clear escalation instructions only
Not applicable
Complaint or clinical incident route
Select one
Documented complaint and escalation process
Handled by practice manager or clinical lead
Handled through regulator or facility route
Needs setup
Safety, escalation, or scope notes for InsideHer routing
Commercial relationships, referral fees, product affiliations, or conflicts to disclose
7. Declaration and submission
This review page generates a structured email package. Because this is a static page,
InsideHer does not receive or store the record unless you send the generated email.
Additional context, ideal next step, or questions for InsideHer
Authorized submitter name
Date submitted
I confirm this record contains no patient names, patient records, or patient-identifiable information.
I consent to InsideHer contacting me about provider onboarding, verification, pilots, or partnership review.
I consent to InsideHer verifying professional registration, public profile details, and practice information before listing.
I understand onboarding is not guaranteed and InsideHer may classify, limit, decline, or request further review before listing or routing.
