Register - Pinnacle MedSuites

Membership Details

First Name

Last Name

Email *

Primary Member Telephone

Specialty / Service Provided

Practice Setup

Different Contact for Patient Inquiries? *YesNo

Different Contact for Admin Inquiries? *YesNo

Preferred Point of Contact For Patient Inquiries

First Name

Last Name

Email Address

Phone

Preferred Point of Contact For Admin Inquiries

First Name

Last Name

Email Address

Phone

Start Date *

Virtual Office *YesNo

Number of Members

Commitment TermPAYGMonth to MonthMulti-monthly

Preferred Payment *Bank DepositCredit or Debit Card

Username *

Password *

Additional Member Contact information

First Name

Last Name

Email Address

Phone

Member 2 Contact information

First Name

Last Name

Email Address

Phone

Member 3 Contact information

First Name

Last Name

Email Address

Phone

Member 4 Contact information

First Name

Last Name

Email Address

Phone

Member 5 Contact information

First Name

Last Name

Email Address

Phone

Member 6 Contact information

First Name

Last Name

Email Address

Phone

Member 7 Contact information

First Name

Last Name

Email Address

Phone

Member 8 Contact information

First Name

Last Name

Email Address

Phone

Member 9 Contact information

First Name

Last Name

Email Address

Phone

Membership Agreement

This Membership Agreement (this “Agreement’), including the Terms and Conditions set out at Appendix “A” and Membership Details form set out above, and any applicable Service Package Addenda, will be effective when signed by both parties as at the date set out below. In the event of any conflict between the Terms and Conditions and the Membership Details form, the Membership Details form shall prevail.

When signing this Agreement, you must have the proper authority to execute this Agreement on behalf of the company listed above and incur the obligations described in this Agreement on behalf of such company.

Agreement ConfirmationI agree to the Terms & Conditions, Payment Authorization Terms & Conditions, and Membership Details.

Membership Length

Type Full Name Here

Your Monthly Total