FVBS Veterinary Hospital Account Registration

FVBS Veterinary Account Registration
Instructions

Complete the form below to set up an account with FVBS for doctor to doctor telemedicine consultations. Next, you will get a fax from our office with a secure credit card authorization form. Call for consult pricing. When your hospital account is set up, we will email your hospital with your new account number and you will be ready to submit your patient's consult form and videos!
Hospital Name:*
Hospital Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary contact person for hospital*

First NameLast Name
Best Email for Hospital*
example@example.com
Hospital Phone Number*

Area CodePhone Number
Hospital Fax Number

Area CodePhone Number
How would you like your consult returned?*

EmailFaxEmail and Fax
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

FVBS Veterinary Account Registration