mConsent TV - Order form

mConsent TV Order form

Practice Name:*

Phone:*

Email:*

Address:*

City:*

State:*

Zip:*

Office Manager Name:*

Doctor / Owner Name:*

Plan Information:

Portal access to make edits, upload your own content, and connect apps.

Up to 7 slides that will be custom developed for your practice highlighting your doctor and staff.

2 screens included with the base package. Additional screens can be added for $25/month per screen.

Pricing Options:* Monthly Plan: $69/month $199 setup fee. Annual plan: $828/year with no set up fee.

Add additional screens: - +

Setup fee: $199
Monthly: $69 + (total additional screens x $25)

Total : $

Contract Details:

If you selected the Annual Plan, you agree to a 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/

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 : 34.239.150.167)

mConsent TV Order form

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