Account Registration

Please enter your office information.   The Account registered below will have Administrative privileges to the account.
Fields in red are required.

Office Information
Business Name
NPI
Address
Address 2
City
State
Zip Code
Phone
Fax
 
Email Address
Website URL
Login Information
Doctor Signature [example: Dr.Jane Doe, O.D.]
License#
DEA
First Name
Last Name
Office ID (3-15 characters)
 
Login ID
Password
 
Confirm Password
 

Password must be at least 4 to 15 characters, and must include at least one upper case character and one numeric digit.

Billing Information

Your account bill be automatically billed per month based on transaction volume. You will be charged $1 per Examination.