Express Form

Request your DispatchExpress account

(Please do not share PHI in this form)

If you are a patient, DO NOT fill out this form, request care or learn more by clicking here.

Providers, please complete the form below to request your DispatchExpress account. Within 24-48 hours of requesting an account, you will receive an activation email from DispatchHealth with the subject line, “You’ve been invited to join DispatchHealth”.

After account activation, login to DispatchExpress to request care for a patient.

If you have not activated your DispatchExpress account and need to request care for a patient, please call 855-239-2670.
Name*

First nameLast name
Title*
Job title
Email*
example@example.com
Phone number
Please enter a valid phone number.
Organization name*
The Organization requesting account setup.
Organization type*
Organization location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip code
Comments
Please verify that you are human.*
Should be Empty: