REGISTRATION FORM

Once you have completed the registration form you will be notified by email when your account is activated and you may then begin to use this system. You will be assigned an account number that must be used with all transmissions.
* Required fields   # If available
* Company or Practice Name
* Street Address
* City State Zip Code
* Telephone No.
(xxx-xxx-xxxx) 		Fax    
# Administrator Phone No.
(xxx-xxx-xxxx) 		Ex.
# Email address        
# Office Manager Phone No.
(xxx-xxx-xxxx) 		Ex.
# Email address        
* Contact Title
* Phone No.
(xxx-xxx-xxxx) 		Ex.    
Your email address will be your user ID and your password can be any combination of eight numbers or letters. It is very important to store this information in a secure place.
ENTER YOUR USER NAME
              Your email address
RE-ENTER YOU USER NAME        
ENTER YOUR PASSWORD        
CONFIRM PASSWORD        
          
 
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