HIPAA Forms Order

Secure Forms Order

Client Information
Thank you for your secure forms order. In order to set up your account, please fill out this form entirely. Once we receive this form, one of our designers will contact you to confirm your order details.
Forms Package*
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Business Name*
Contact Name*
Office Email Address*
Enter address you want to be notified at that a new form was submitted
Business Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Phone Number*

Area CodePhone Number
Secondary phone number we can reach you at in case your office is closed

Area CodePhone Number
Website Address
Please list all of the forms you would like us to create for you?
Separate each form title with a comma
If you would like us to duplicate your existing forms, upload current copies

Browse Files
File types: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif Cancelof
Who will add the forms to your website?*
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What format would you like to retrieve your form submission data?*
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Google Email Address*
We use Google Drive to store data and it requires a Gmail account for access. This will not be used for email notifications.
Billing Preference*
Disclosure and Consent

I authorize Jelly Websites to charge the above monthly package amount selected as well as the one-time $50 account activation fee. I also confirm that all information stated is true and correct to the best of my knowledge. To learn more about our Terms and Conditions click here https://jellywebsites.com/terms-of-service.html
Confirmation*

I Agree to Terms Conditions as above
Signature*

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Secure Forms Order