Corp Group Upgrade Form

JotForm Name*
Are you an existing ALLYDVM user?*
Please speak with your ALLYDVM account representative for the proper order form link.
What's the name of the corporate group that you belong to?*
Confirm that you belong to NVA?*

Two-Way Texting

Two-Way Texting
Do you want your existing landline phone number to be your text (sms) number?*

Yes (I want to try and use my existing business number as my sms number)No (I want a new number assigned with my area code)
What is the phone number?*
Do you use SMS on this phone number right now?*

YesNo
Who is the SMS provider?*
*Please note that you will have to cancel with your current SMS provider before we can host your SMS services on this phone line.
Who in your practice can we call during setup of this SMS number?

First NameLast Name
(In order to host your SMS number, a phone verification call is required where the end-user answers the phone and passes back a security token to Twilio.)
Email of this person?
What is the name of the person listed on the bill for this phone number?

First NameLast Name
(This person will need to authorize the usage of this number.)
Loyalty Program

Loyalty Program
(Only available to Avimark, Cornerstone, or Infinity users)
Analytics Package

Analytics Package
Dashboard User 1 Email*
Dashboard User 2 Email
Dashboard User 3 Email
Retention Calendar

Retention Calendar
Please note that this option is only available if you are currently a paying user of our Communications System. If you are not, please speak with your account rep for the correct order form.
Communication System

Communication System
Please note that this option is only available if you are currently a paying user of our Retention Calendar. If you are not, please speak with your account rep for the correct order form.
Additional Discounts:
- Setup Fee Waived ($485 Value)
- USA Postcard Discount ($0.16/Card)
  - Standard postcards are $1.02/card $0.86/card
  - Custom postcards are $1.04/card $0.88/card

Practice Name*
Practice ID
login to ALLYDVM > click gear icon top right > click Practice Profile > locate Practice ID near top of page
Practice Website*
Enter your website url. If you don't have one, enter www.none.com.
Practice Address*

Street Address

Street Address Line 2

CityState / Region / Province

Postal / Zip Code
Country*
Country
US States*
State / Region / Province
Canada States*
State / Region / Province
Practice Address State Selected
Contact Person

First NameLast Name
Contact Person's Email*
Contact Person's Phone Number
Agree to Terms
By clicking 'Submit' you agree to ALLYDVM's Terms of Service and Privacy Policy.
Today's Date*

MonthDayYear
Date
You have read and accept the Terms and Conditions and understand the Privacy Policy. You also agree to purchase the services indicated in this order form and authorize ALLYDVM to activate your add-ons.*

Yes
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