877-203-6767
mConsent Order Sheet
Reactivate your mConsent account by completing the order form below
Practice Name:
*
Phone:
*
Email:
*
Address:
*
City:
*
State:
*
Zip:
*
Office Manager Name:
*
Doctor / Owner Name:
*
Pricing Options:
*
$169/month (month to month contract)
$149/month (12 month commitment)
$299/month (Consolidate and Save-12 month commitment)
Plan Information:
What's Included in your plan: Digitized forms that can be emailed/texted to patients Integration with your practice management system (If available) Free support included by email/phone (8am-5pm CST) Forms Library included (you can use any forms from the library as long as you are customer of SRS) Digitization of your forms is covered by the one time setup fee. Additional custom patient forms may be added for a one-time cost of $10 / form. SRS does not provide any iPad hardware but only software for your office, recommended iPad Specifications: 7th Generation (2017) or newer, iOS 14.0 or above
What's Included in your plan: Digitized forms that can be emailed/texted to patients Integration with your practice management system (If available) Free support included by email/phone (8am-5pm CST) Forms Library included (you can use any forms from the library as long as you are customer of SRS) Digitization of your forms is covered by the one time setup fee. Additional custom patient forms may be added for a one-time cost of $10 / form. SRS does not provide any iPad hardware but only software for your office, recommended iPad Specifications: 7th Generation (2017) or newer, iOS 14.0 or above
What's Included in your plan: Digitized forms that can be emailed/texted to patients Integration with your practice management system (If available) Free support included by email/phone (8am-5pm CST) Forms Library included (you can use any forms from the library as long as you are customer of SRS) Digitization of your forms is covered by the one time setup fee. Additional custom patient forms may be added for a one-time cost of $10 / form. Treatment plans, Treatment Plan Reminders, Patient Communication, Reputation Management, Practice App, Text 2 Pay. SRS does not provide any iPad hardware but only software for your office, recommended iPad Specifications: 7th Generation (2017) or newer, iOS 14.0 or above
Contract Details:
If you selected “Month-to-Month Contract” , Cancellation requests must be submitted via email to SRS at support@srswebsolutions.com at least 30 days before the cancellation date. mConsent API must be removed from your practice server by the mConsent support team for the cancellation to be considered final. By signing this order sheet, you are agreeing to following terms and conditions of SRS Web Solutions Inc: http://srswebsolutions.com/terms-services/
If you selected “12-Month Commitment”, Cancellation requests must be submitted via email to SRS at support@srswebsolutions.com at least 60 days before the contract expiration date. If a timely cancellation request is not received, the contract will automatically renew for a 12-month period . mConsent API must be removed from your practice server by the mConsent support team for the cancellation to be considered final. By signing this order sheet, you are agreeing to following terms and conditions of SRS Web Solutions Inc: http://srswebsolutions.com/terms-services/ This order agreement (the “Order”) shall be effective upon execution by both parties (the “Effective Date”) and shall remain in effect until the one year anniversary of the Service Start Date, unless earlier terminated in accordance with the provisions herein. This Order shall automatically renew for successive one year periods on the anniversary of the Service Start Date, unless either party hereto provides the other with a written notice of non-renewal at least sixty (60) days prior to the expiration date for the then-current term. Notwithstanding the foregoing, this Order may be terminated: a) by SRS due to a material breach of this Order or the Terms and Conditions (which are made a part of this Order) by the Client, by providing the Client thirty (30) days' prior written notice and an opportunity to cure the material breach set forth in the notice within such thirty (30) day period, if curable (for the avoidance of doubt, failure to make any payment due to Client shall be considered a material breach hereunder), and such termination by SRS shall not relieve the Client from payment for the remainder of the then-current subscription term; b) immediately by either Party in the event the other Party: (i) terminates or suspends its business; (ii) becomes subject to any bankruptcy, insolvency or similar proceeding under federal, state or foreign laws or statutes, provided that such proceedings are not dismissed within sixty (60) calendar days of commencement of the same; (iii) becomes insolvent or subject to the control of a trustee, receiver or similar authority; or (iv) has liquidated its business, voluntarily or involuntarily; c) by the Client during the initial term of this Order for any reason by providing written notice to SRS within thirty (30) days from the initial Effective Date, in which case the Client shall receive a full refund for any monies paid to SRS pursuant to this Order; or (d) by the Client upon the occurrence of the following and receipt of written notice to SRS with proof of same: (i) the death of the Client (or the majority owner of the Client, if an entity, so long as the majority owner is also the practicing doctor); (ii) the totally and permanent disability of the Client (or the majority owner of the Client, if an entity, so long as the majority owner is also the practicing doctor); or (iii) sale of the Client’s business for which the software is being utilized. Non-renewal or termination notices by the Client must be submitted via email to SRS at support@srswebsolutions.com. mConsent API must be removed from the Client’s practice server by the mConsent support team for the service termination to be considered final. The option to pay for the subscription via installments is for convenience only and the full subscription amount is considered earned and non-refundable as of the Effective Date, unless otherwise expressly provided for here in.
If you selected “12-Month Commitment”, Cancellation requests must be submitted via email to SRS at support@srswebsolutions.com at least 60 days before the contract expiration date. If a timely cancellation request is not received, the contract will automatically renew for a 12-month period . mConsent API must be removed from your practice server by the mConsent support team for the cancellation to be considered final. By signing this order sheet, you are agreeing to following terms and conditions of SRS Web Solutions Inc: http://srswebsolutions.com/terms-services/ This order agreement (the “Order”) shall be effective upon execution by both parties (the “Effective Date”) and shall remain in effect until the one year anniversary of the Service Start Date, unless earlier terminated in accordance with the provisions herein. This Order shall automatically renew for successive one year periods on the anniversary of the Service Start Date, unless either party hereto provides the other with a written notice of non-renewal at least sixty (60) days prior to the expiration date for the then-current term. Notwithstanding the foregoing, this Order may be terminated: (a) by SRS due to a material breach of this Order or the Terms and Conditions (which are made a part of this Order) by the Client, by providing the Client thirty (30) days' prior written notice and an opportunity to cure the material breach set forth in the notice within such thirty (30) day period, if curable (for the avoidance of doubt, failure to make any payment due to Client shall be considered a material breach hereunder), and such termination by SRS shall not relieve the Client from payment for the remainder of the then-current subscription term; (b) immediately by either Party in the event the other Party: (i) terminates or suspends its business; (ii) becomes subject to any bankruptcy, insolvency or similar proceeding under federal, state or foreign laws or statutes, provided that such proceedings are not dismissed within sixty (60) calendar days of commencement of the same; (iii) becomes insolvent or subject to the control of a trustee, receiver or similar authority; or (iv) has liquidated its business, voluntarily or involuntarily; (c) by the Client during the initial term of this Order for any reason by providing written notice to SRS within thirty (30) days from the initial Effective Date, in which case the Client shall receive a full refund for any monies paid to SRS pursuant to this Order; or (d) by the Client upon the occurrence of the following and receipt of written notice to SRS with proof of same: (i) the death of the Client (or the majority owner of the Client, if an entity, so long as the majority owner is also the practicing doctor); (ii) the totally and permanent disability of the Client (or the majority owner of the Client, if an entity, so long as the majority owner is also the practicing doctor); or (iii) sale of the Client’s business for which the software is being utilized. Non-renewal or termination notices by the Client must be submitted via email to SRS at support@srswebsolutions.com. mConsent API must be removed from the Client’s practice server by the mConsent support team for the service termination to be considered final. The option to pay for the subscription via installments is for convenience only and the full subscription amount is considered earned and non-refundable as of the Effective Date, unless otherwise expressly provided for herein.
Next Steps:
Please click on and read the terms and conditions and contract details(see above) to make sure you understand all of the details involved with us working together. It’s very important to us that everything is transparent and understandable from the beginning so that we can build a solid foundation for a great working relationship.
If you have any questions at all, please let us know. We are happy to clarify and discuss any concerns that you may have. Please know that we are committed to working for you to make our product the best that it can be for your practice.
Once you have reviewed everything and are ready to move forward, please click the 'sign here' button below.
Add your electronic signature in the box that prompts you to make the acceptance official, you will be asked to make a payment via a secure credit card payment system
We will also email you a separate copy of the signed agreement for your records.
If you have any questions or concerns, please contact us. Our telephone number is 877-203-6767.
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 :
18.97.14.90)
Pay now
We also offer
