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Request Proposal
Just tell us how to contact you (and a couple things about your practice), and one of our Account Executives will be in touch within 2-3 business days to discuss our integrated solution for your practice management system.
Practice Info
Tell us a little bit about yourself and your practice.
Practice Name
*
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Alternate Phone
Time Zone
*
(Select)
PT - Pacific
MT - Mountain
CT - Central
ET - Eastern
AT - Atlantic
Best Time to Contact
*
(Select)
8am - 10am
10am - 12pm
12pm - 2pm
2pm - 4pm
4pm - 6pm
Processing Information
Tell us a little bit about how you accept payments.
How many practice locations do you have?
*
(Select)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20+
How do you accept payments? (Check all that apply)
Face to face, front-desk
Through my practice website
On the go, mobile
Manual key enter
Notes
Upload Statements
Uploading your prior processing statements will help us tailor a proposal just for you and your practice.
Click "Choose Files" to browse for files on your computer or mobile device. Up to 12 files can be uploaded.
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