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Contents


Business Information

Business Information :

Date: Client Name :

Tax ID# :


Business Hours of Operation :

Lunch Period From :

Lunch Period To :


Preferred Payment Method:



Administrative Contact Information


Administrative Contact Information :




Primary Business Contact (Practice Owner)

Primary Business Contact (Practice Owner)

Primary Business Contact (Practice Owner)

Office Manager

Internal Technical Contact


Internal Billing Contact



Data from AdministrativeForm


Data from BusinessInformationForm


Data merged from both Forms (error) NOT WORKING YET

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