Medical Practice Onboarding

Organization details

Fields marked with an asterisk are required.

Organization Details

Tell us about the clinic that needs to be onboarded.

Practice Legal Name *

Choose Subdomain Name *

Use only lowercase letters without spacing, no characters or numbers.

Location Name *

EHR / EMR System in Use *

Name of the EHR/EMR used by your organisation

Address *

City *

State *

Zip *

Provider Information

1. Provider Name *

NPI *

2. Provider Name

NPI

3. Provider Name

NPI

Primary Contact Information

Identify the main person coordinating onboarding.

Practice Email *

Primary office email

Practice Phone *

Contact Name *

Manager or Primary Contact

Contact Role *

Owner, Manager, Clerk

Contact Phone *

Text capable number

Billing Address Information

Address *

City *

State *

Zip *

Same as shipping

Same shipping address

Shipping Address Information

Address

City

State

Zip

Make your organization recognizable

Add the details your team will use on its account. Your profile is created after staff approval.

Identity and branding

Add the public-facing details for your organization.

Display name:

Legal name:

Dba name:

Entity type:

Website:

Timezone:

Logo: Raster formats only (png, jpg, jpeg, webp). Max size: 10 MB.

Contact and headquarters

Use an address and contact details your team can maintain.

Contact email:

Contact phone:

Hq address line1:

Hq address line2:

Hq city:

Hq state:

Hq zip:

Mailing address

Optional. Complete this if correspondence should go to another address.

Mailing address line1:

Mailing address line2:

Mailing city:

Mailing state:

Mailing zip:

By submitting this form, you confirm the information is accurate to the best of your knowledge.