Please complete the form below. Step 1 of 4 25% Your InformationYour Name Name of person who's filling out this form.Your Email What is the best email address to reach you? Business InformationName of Practice Owner If more than one owner, list all.Business Name Name listed on business license or utility bill.Has the practice ever changed names or rebranded? Yes No What year was practice rebranded? If you don't know, please give an estimated year (i.e. 2005).Previous Name of Practice Business InformationCurrent Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Have you ever relocated your practice? Yes No Don't know What year did the practice relocate? If you don't know, please give an estimated year (i.e. 2005).Previous Address Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Office Phone NumberDoes your practice use call tracking? Yes No Used to, but no longer Don't know More InfoPlease provide call tracking details including service provider, marketing agency, etc.Official Business Email Email address used to to communicate with patients.Does your practice use email encryption for HIPAA? Yes No Don't know Business Information, Cont.Year Practice Opened Business HoursPayments Accepted Cash Check Visa MasterCard Discover American Express 3rd Party Financing (ie CareCredit) In-House Financing Other Practitioner InformationPlease list each practitioner associated with the office.NumberUntitled NameThis field is for validation purposes and should be left unchanged. Δ
