New Medical Practice: Account Information

NEW MEDICAL PRACTICE

ACCOUNT INFORMATION
AREAS OF INTERESTS *

Recurring Revenue – Dermatology / Anti-Aging Recurring Revenue – Hormones Recurring Revenue – IV Nutrition Recurring Revenue – Peptides Recurring Revenue – Sexual Health Recurring Revenue – Thyroid Recurring Revenue – Weight Loss Cost Savings – Credit Card Processing Cost Savings – EMR Cost Savings – Insurance Cost Savings – Laboratory Cost Savings – Marketing Cost Savings – Products Cost Savings – Supplies
PRACTICE INFORMATION
Business Name *
Business Phone *
Please enter a valid phone number.
Business Fax
Please enter a valid phone number.
Business/Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PRIMARY CONTACT
Primary Contact *

First Name Last Name
Preferred Method of Contact *
Primary Contact Email *
example@example.com
Primary Contact Phone *
Please enter a valid phone number.
DIRECT DEPOSIT AUTHORIZATION

Banking Information

	Remit Payment to:
Name of Banking Institution
Account Type (Checking or Savings)
Bank Routing Number
Bank Account Number

Authorization
{businessName56} authorizes Joi Partners, LLC. d/b/a The JOI Group and its bank to automatically deposit funds into the account listed above (this includes authorization to correct entries made in error). This authorization will remain in effect until written notice is given to cancel it.
Print Name *

First Name Last Name
Job Title *
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty:

NEW MEDICAL PRACTICE