Sign Up for a Monthly Subscription Plan NOW and the Setup Fee is
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First Name
Last Name
Contact Title
Name of Practice
Billing Address
City
State
Zip
Country
Office Phone
E-mail
FAX
Web Site
What Type of Practice do you operate?
How many site locations will you be using with this service?
This does not effect your billing rates, it just helps
us set up your account so that the information from all your sites will
appear on the forms.
How many practitioners will be covered by this order?
This does effect your billing rates, our plans are based on
the number of practitioners.
What plan are you signing up for?
Remember: You can bill $ 15 per form,
that will more than pay for our services, not to mention the speed and
efficiency your office will gain.
Monthly Subscription Rate:
$
Initial Set Up
Fee:
$
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