New Medical Practice: Account Information

NEW MEDICAL PRACTICE

ACCOUNT INFORMATION
AREAS OF INTERESTS*

Recurring Revenue – DermatologyRecurring Revenue – IV NutritionRecurring Revenue – Sexual HealthRecurring Revenue – Weight LossRecurring Revenue – HormonesRecurring Revenue – PeptidesRecurring Revenue – ThyroidCost Savings – Credit Card ProcessingCost Savings – EMRCost Savings – LaboratoryCost Savings – InsuranceCost Savings – MarketingCost Savings – ProductsCost 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

CityState / Province

Postal / Zip Code
PRIMARY CONTACT
Primary Contact*

First NameLast Name
Preferred Method of Contact*
Primary Contact Email*
example@example.com
Primary Contact Phone*
Please enter a valid phone number.
DIRECT DEPOSIT AUTHORIZATION
Your direct deposit account information will be collected by phone.

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 NameLast Name
Job Title*
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

NEW MEDICAL PRACTICE