Complete this form and click [Submit] to retrieve your activation key. Please verify that all fields accurately reflect the practice you are registering. Once you have successfully registered your product and have the activation key, print this page to keep as a reference for the future.

VAR#VAR (reseller) Name Number of Users*Serial Number *Provider First Name Middle*Last Name *Required fields

 

 

 

 

*Registration/Practice Name*Contact First Name*Street Address*City*StatePractice Specialty*E-mail Address(No Punctuation)*Phone

 

 

*Last Name

 

                                                                               *Zip     Fax(No Punctuation)   *Version  Close