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Account

1 of 4

Username: First Name: Last Name: NPI: Specialty (optional):

Contact

2 of 4

Email: Confirm Email: Phone: Fax (optional): Address: City: State: Zip:

Payment

3 of 4

First Name: Last Name: Billing Address is... : Same as Mailing. Different from Mailing.

Billing Address: City: State: Zip:

Card Number: Exp. Date: / CSC Code:

Review and Submit

4 of 4

Account:

Username:

Name:

NPI:

Specialty:

Contact:

Email:

Phone:

Fax:

Mailing Address:

Payment:

First Name:

Last Name:

Billing Address: Same as Mailing.

Card Number:

Exp. Date: /

CSC:

Summary:

Set-up Fee: $50 Tax: $0 Usage charge: $-- (to be determined and billed the following month) $3 per small study $4 per large study $1 advanced toolset $50 monthly minimum

TOTAL: $50

I agree to the terms and conditions.

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