Register to Become a Vital Tears Provider

Complete the form below to become a Vital Tears provider.
Each physician within the clinic will be assigned a username, which requires a unique email address.
A clinic username will be assigned to the primary contact by Vital Tears.
Once submitted, a member of our Vital Tears team will personally follow up.

Clinic Information

Primary contact for Vital Tears such as an office administrative assistant, scheduler, nurse or scribe.

(Provide mobile contact or direct line if available)

Office Hours


Enter the name, license and contact information for each physician at this clinic location. Each physician must have a unique email address.

Add Physician

Additional Coordinators

Enter the name and contact information of any additional coordinators, along with the name(s) of the physician(s) they serve (or "all" if applicable). This could be an office administrative assistant, nurse or scribe. Please do not re-enter a physician's name as the coordinator.

Add Coordinator

Blood Collection

Vital Tears partners with a network of blood collection facilities and a mobile phlebotomy service.