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Contents


Business Information

Date:

Client Name:

Tax ID#:



Business Hours of Operation:



Lunch Period From:



Lunch Period To:



Preferred Payment Method:




Administrative Contact Information

Client Name:

Primary Business Contact (Practice Owner) Primary Business Contact (Practice Owner) Primary Business Contact (Practice Owner)

Office Manager Internal Technical Contact Internal Billing Contact



Staff Member Contact Information

Client Name:

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Email Account Information

Client Name:

Account User First & Last Name or Group Name
Email Address
Password
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