Practice Registration

Complete the form below to create your account. If you have any questions please contact us. For additional information regarding each field you may hover over the question mark icons.

* Indicates a required field.

Practice (Business Entity) Information

Legal Name *

Office Email *

Office Phone *

Address *

Address Continued

City *

State *

Postal Code *

Tax ID Number *

NPI (Type 2) *

Taxonomy Code *

Administrator Information

First Name *

Last Name *

Email *

Password *

Confirm Password *

Legal

SAAS Agreement *

Choose File Upload a signed copy of the SAAS agreement. Click HERE to download the agreement.

I agree to the Terms of Agreement

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