AllyDVM Order Form

AllyDVM Order Form
JotForm Name
Enter your referral code or the name(s) of any corporate group, network, or purchasing group that you belong to if applicable (you may enter multiple).
NOTE! If you are a corporate group member, please click here to use our corporate group order form. Thank you!
Confirm that you're a TVC member.*
Confirm that you belong to Blue River PetCare.*
Confirm that you qualify for the New Practice Promotion discounted pricing.*
Confirm that you belong to VSG.*
Confirm that you belong to PetWell Partners.*
Confirm that you belong to VISN.*
Contact Person*

First NameLast Name
Contact Person's Email*
Full Practice Name*
Is AllyDVM currently installed on your server?*
Practice ID
If you are currently installed with AllyDVM, enter your Practice ID here.
Practice Email Address*
Practice/Front Desk Phone*
Practice Website*
Enter your website URL. If you don't have one, enter www.none.com.
Practice Manager*
Practice Manager Email*
Who is your Operations Manager?*
Who is your Regional Manager?*
TVC Owner Number*
TVC Membership Enrollment Date*

MonthDayYear
MM/DD/YYYY
VSG Group Number*
Practice Address*

Street Address

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
Practice Management System*

MWI Account ID
All AllyDVM billing is processed through MWI. Please locate your current MWI Account Number if applicable.
Who referred you to AllyDVM?
(MWI, AllyDVM website, Colleague, etc.)
Name of your MWI Rep
(if applicable)
Referral Code
(if applicable)
Agree to Terms

_________________________________________________________________________________________________________________

In order to start your account, you must read and agree to AllyDVM's Terms and Conditions and Privacy Policy.
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 account.*

Yes
Accepted By*
First and Last Name Only
Today's Date*

MonthDayYear
MM/DD/YYYY
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