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Email
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Main Contact First Name
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Main Contact Last Name
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Main Contact Role
Phone Number
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Hospital Full Name (No acronyms)
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Hospital Website
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Hospital Street Address
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Hospital Street address 2
Hospital City
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Hospital State/Region
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Hospital Postal code
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Hospital Country/Region
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Have you had a DVMSTAT Account Previously?
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Please Select
Yes
No
What consult services are most important to be able to provide to your patients? Choose as many as apply.
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All Services
Immediate Telephone Consultations
Emergency/Critical Care
Oncology
Internal Medicine
Cardiology
Neurology
Diagnostic Abdominal Ultrasound Interpretation
Echocardiogram Interpretation
ECG Interpretation
Surgery
Other
Billing Contact First Name
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Billing Contact Last name
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Billing Contact Email
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Billing Contact Phone Number
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Payment Method Preferred
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Please Select
Credit card on file - Can be set up directly through STRIPE, a secure payment platform utilized by YourViewDr, our medical records software
ACH - Can be set up directly through STRIPE, a secure payment platform utilized by YourViewDr, our medical records software
Check - Mailing Address: 20 Towne Drive, Suite 170, Bluffton, SC 29910
Corporate Payment Arrangements Required - Please answer question below with additional information
For Users with Corporate Payment Accounts: Please provide additional details
Net 15/30 terms, corporate email & address for billing, notes on any additional forms or neds for payment to be rendered, etc.
Medical Record's Email Address
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All consult reports will be sent to this address. *This is also your LOGIN email to the DVMSTAT medical records portal.
Name of doctor(s) to be listed as "Requesting Clinician" on your reports
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*Doctors name, Credentials (ie. Sam Smith, DVM), and email address. **Note: This allows the Practice Manager/Account Owner to track payment/collection of fees and ensures that the correct doctor is communicated with by our consultants when case follow-up is needed. ***The doctor will receive a copy of the report as well if their name is selected in the dropdown menu in the DVMSTAT platform.
Would you like to schedule a phone call with DVMSTAT to discuss your account, discuss consultation questions or to learn more before you submit your first consultation?
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Please Select
Yes
No
If Yes, please provide your name, email and phone number as well as preferred days of the week and times. We will reach out to you via email to schedule a convenient time for a phone call.
DVMSTAT Billing Policy Consent:
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Account Billing:
Accounts are billed every 30 days via email for consults completed during the prior calendar month with net 30 terms. Billing email will be required at the time of registration. Paid receipts will be provided to the billing email.
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I have read, understand and agree to the DVMSTAT Account Billing Policy
I do NOT agree to the DVMSTAT Account Billing Policy
DVMSTAT Policy Consent:
*Payment methods accepted:
credit card on file (preferred), check, or ACH.
**Late Payment Policy:
A 10% Late fee will be applied to all accounts >60 days late and an additional 10% late fee will be applied every 90 days until the account is paid in full.
***Cessation of Service Policy for late accounts:
Late payments >90 days will result in the cessation of service until the account payment is up to date.
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I have read, understand and agree to the DVMSTAT Account Policies
I do NOT agree to the DVMSTAT Account Policies
Name & Hospital Role/Credentials of Individual Completing Hospital Registration Form
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How did you hear about DVMSTAT?
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Veterinary Colleague
Facebook/Instagram
Webinar/Podcast
LinkedIn
DVMSTAT Email
Palmetto Vet Conference
Fetch Conference
Southeast Vet Conference
VMX
At Another Conference
Other
Submit