Account Setup

Account Information
Clinic or Practice Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone Number
Fax Number
Physician Name
Name
First Last
Physician NPI
Billing Address
Same as Account Information
- Same as Account Information
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Office
Name (Primary Contact)
Title
Email Address (Primary Contact) **
Phone Number (Primary Contact)
Secondary Office
Name (Secondary Contact)
Title
Email Address (Secondary Contact)
Phone Number (Secondary Contact)
Distributor
Distributor Name
Distributor Email
Distributor Phone
Sales Representative
Sales Rep Name
Sales Rep Email
Sales Rep Phone

Account Information