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Practice Information

12 month contract ($50/month for a total of $600/year)
6 month contract ($60/month for a total of $360/half year)

Number of staff*: (price is half the provider rate per staff member)
Name*:
Email Address*:
Phone*:
Address*:
Address Line 2:
City*:
State*:
Zip Code*:
DEA Number*:

Mailing Address (if different) Address:
Address Line 2:
City:
State:
Zip Code:

Optional Information Practice Name:
Operating System:
FAX:
Cell Phone:
Pager:
EIN:
NPI:
Medical license #:

Customer information is kept confidential. Vālant does not rent or sell customer information.