Online Enrollment Form Online Enrollment Form for Veterinarians Please enable JavaScript in your browser to complete this form.Clinic Name:Legal business name (If Different):Shipping AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeBilling AddressCheck if same as shippingAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone:Fax: How would you like your reports/ statements delivered? Preop/Screening: Verbal results with: e-mailed reportfaxed reportno written reportboth e-mailed and faxed Full Reports (Phone/ STAT/ Code Red): Verbal results with: e-mailed reportfaxed reportboth e-mailed and faxedStatements: e-mailedsent via USPSClinic e-mail: Manager/Acct Contact name: Doctor's Name(s):Owner/Principal's Name:Social Sec #:Home Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone:How did you hear about us? Billing Options (choose one):I prefer to be billed monthly* (Social Security Number Required for Credit Purposes)I prefer to have my credit card automatically debited monthly (Please fill out below.)Credit Card Information:VisaMastercardDiscoverCard Number:Exp. Date:3-digit verification code:Name On Account:Billing Address of Credit Card:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you own an ECG Transmitter?Yes (describe below)NoNo, I am interested in purchasing onePlease describe what type of ECG Transmitter you currently useTerms are payable upon receipt. Finance charges of 1.5% per month (18% Annual) will be assessed on any balance unpaid after 30 days. Past due accounts are subject to credit restrictions and credit holds. Payment may be made by business check, Visa, MasterCard and Discover. There is a returned check fee of $25.00. By signing this agreement, I personally consent to pay any outstanding debt, including collection and/or any reasonable legal fees. I have provided the correct information above and I agree to the terms and conditions contained herein.CommentSubmit