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Are you opening a new clinic or satellite practice? Learn more about getting started.  

To become a customer, please fill out our form below, or download our application.

SECTION I: CUSTOMER INFORMATION

 
 
 

Please provide an email address that will be directed to persons authorized to manage all aspects of your account including bill matters. This email will be used to provide notifications of your online statement availability, corporate communications, and offerings.

   
   
 
 
 
   
 
 
 
 
   
 

SECTION II: PRACTICE Type (Choose all that apply)





 

SECTION III: BUSINESS INFORMATION (as applicable)

 
 

SECTION IV: WHAT TYPE OF PRODUCTS TO YOU INTEND TO PURCHASE? Check all that apply

 

SECTION V: PAYMENT TERMS REQUEST

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