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).
Confirm you wish to focus on standalone services?*
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*

Our Most Popular Bundles*
Our Most Popular Bundles*
RC+Comms+PetPage
RC+Comms+PetPage+TWT
RC+Comms+PetPage+TWT+TeleHealth
Individual Services
Boost Services
Amplify Services
Maximize Services
Our Most Popular Bundle Services
Select Your Services*
RC+Comms
RC+Comms+TWT
Communication System
Retention Calender
PetPage Patient Portal App
Two-Way Texting
Telehealth
Analytics
Loyalty
Blue river Services
Select Your Services*
RC+Comms+PetPage
NPP Services
Select Your Services*
RC+Comms+PetPage+TWT
Automated Postcards Only-No other comms
VSG DATALINK Analytics & Transfer
Bundle - Focus
Bundle - Boost
Bundle - Amplify
Bundle - Maximize
VSG Services
Focus Services
Standalone Services*
Standalone Services*
Standalone Services*
Standalone Services*
Standalone Services*
Individual Services
Standalone Services
Please check the box to confirm you are aware that Boost Bundle will be invoiced at the discounted rate of $185/mo for the first year of your subscription. After that time the cost will return to the standard rate of $325/mo.
Please confirm you are officially opting in for our Two-Way Texting Feature:*
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?
Please enter a valid phone number.
Do you use SMS on this phone number right now?*

YesNo
Who is the SMS provider?*
Who in your practice can we call during setup of this SMS number?*
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.
What is the name of the person listed on the bill for this phone number?*
What is the name of the person listed on the bill for this phone number?
Please confirm that you are officially opting in for our Loyalty Program:*
Loyalty Program

TrueFalse
Please confirm that you are officially opting in for the Analytics Package:*
Analytics Package

TrueFalse
Please confirm you are opting in for VSG Analytics and DATALINK Transfer. Revenue data will be uploaded quarterly into DATALINK for benchmarking purposes.
Dashboard User 1 Email*
Dashboard User 2 Email
(if needed)
Dashboard User 3 Email
(if needed)
VMG Trends Report

This is only for members that do not want to use any of the AllyDVM features, but do want to have their data included in the monthly VSG Trends report (emailed to practice owners once a month).
Automated Postcards are available with our Communication System. Postcard pricing in the US is $0.99/standard card or $1.01/custom card. In Canada the postcard pricing is $1.22/standard card or $1.24/custom card.

*Online Booking is available for select practice management systems.

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
Should be Empty: