877-203-6767
Account receivable for Healthcare
Practice Name:
*
Phone:
*
Email:
*
Address:
*
City:
*
State:
*
Zip:
*
Office Manager Name:
*
Doctor / Owner Name:
*
Plan Information:
mConsent Text-2-Pay Digital Forms - Online and iPad app E-sign Treatment Plan Onboarding and Staff Training Integration with your PMS ive support: Phone, Chat and Email
Pricing Options:
*
Monthly Plan: $1
Add additional screens:
-
+
Setup fee: $199
Monthly: $69 + (
total additional screens
x $25)
Total : $
By signing this order sheet, you are agreeing to following terms and conditions of SRS Web Solutions Inc:
http://srswebsolutions.com/terms-services/
Next Steps:
Finalize payment
Complete order form to specify preferences for account creation
Once your account has been created, you will receive login information
Login to your tv.mconsent.net portal and explore!
If you cancel your mConsent account and decide to come back:
Please contact our sales department at 877-203-6767 ext. 1.
You may be subject to set up and integration fees for some forms.
Authorized name:
*
Authorized Signature:
*
(Draw Signature)
Clear Signature
Date:
I agree with the
Terms and Conditions
of working with SRS Web Solutions
(Your IP Address :
35.170.81.33)
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