New Customer Registration Form

Welcome to iTRUST Cloud EHR!

Fill in required fields to active your account!
Account Information
Company name*
Contact name*

First NameLast Name
Company address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Contact number*

Area CodePhone Number
Company email*
example@example.com
Referred by

Practice Information
Practice name*
Practice address same as company address?*

YesNo
Practice address*

Street Address

Street Address 2

CityState

Zip CodeCountry
Practice email*
example@example.com
Practice phone*

Area CodePhone Number
Practice fax

Area CodePhone Number
Practice Website
Tax ID (EIN)
Store NPI
Unique User Logins*
Add 2nd Practice?*

YesNo

2nd Practice Information
Practice name*
Practice address*

Street Address

Street Address 2

CityState / Province

Postal / Zip CodeCountry
Practice email*
example@example.com
Practice phone*

Area CodePhone Number
Practice fax

Area CodePhone Number
Practice Website
Tax ID (EIN)
Store NPI
Unique User Logins*
Add 3rd Practice?*

YesNo

3rd Practice Information
Practice name*
Practice address*

Street Address

Street Address 2

CityState / Province

Postal / Zip CodeCountry
Practice email*
example@example.com
Practice phone*

Area CodePhone Number
Practice fax

Area CodePhone Number
Practice Website
Tax ID (EIN)
Store NPI
Unique User Logins*
Add 4th Practice?*

YesNo

4th Practice Information
Practice name*
Practice address*

Street Address

Street Address 2

CityState / Province

Postal / Zip CodeCountry
Practice email*
example@example.com
Practice phone*

Area CodePhone Number
Practice fax

Area CodePhone Number
Practice Website
Tax ID (EIN)
Store NPI
Unique User Logins*
Add 5th Practice?*

YesNo

5th Practice Information
Practice name*
Practice address*

Street Address

Street Address 2

CityState / Province

Postal / Zip CodeCountry
Practice email*
example@example.com
Practice phone*

Area CodePhone Number
Practice fax

Area CodePhone Number
Practice Website
Tax ID (EIN)
Store NPI
Unique User Logins*

Payment and billing

$99/m
billed yearly
per doctor per location

Billed upfront

33% Savings over monthly

$0 staff accounts
$0 set up & no contract

$149/m
billed monthly
per doctor per location

$0 staff accounts
$0 set up & no contract

Billing*

YearlyMonthly

Payment info*

No charge will be made this is used for verification purposes only$0.01

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

I agree to allow iTRUST.io LLC to withdraw from my credit card monthly or yearly for the amount corresponding to the correct pricing tier, which is based on the actual number of doctors users at each actual number of practice location.

I understand and agree to allow verification of actual user Accounts per location at any time during use of the system. I understand and agree export files take up to 45 days, and can only be generate after there is no write actions performed on the system. I have read and agree to iTRUST.io LLC’s terms of use and HIPAA business associate agreement.
Submitted by*

First NameLast Name
Date*

MonthDayYear
Date
I agree*

Yes, by checking this box I agree to the above terms.
Should be Empty: