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're enrolled in Vetcelerator
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?
AllyConnect ID
AllyConnect ID can be located in your account at https://connect.allydvm.com within Gearwheel > Practice Profile.
Practice Email Address
Practice/Front Desk Phone
Format: (000) 000-0000.
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
Vetcelerator Member Number
TVC Membership Enrollment Date

MonthDayYear
MM/DD/YYYY
Vetcelerator 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
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
Data Only No Services
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 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?
What is the phone number?
Please enter a valid phone number.Format: (000) 000-0000.
Do you use SMS on this phone number right now?
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
Please confirm that you are officially opting in for the Analytics Package:
Analytics Package
Dashboard User 1 Email
Dashboard User 2 Email
(if needed)
Dashboard User 3 Email
(if needed)
VMG Trends Report
Automated Postcards are available with our Communication System. Postcard pricing in the US is $1.04/standard card or $1.06/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.
Accepted By
First and Last Name Only
EmailSubjectBuilder
Today's Date

MonthDayYear
MM/DD/YYYY
Should be Empty: