Furscription Jotform

JotForm Name*

Are you currently installed with AllyDVM for any MWI solutions (AllyDVM features, Vet-Telligence or Repleni-Trac Vault)?*

Practice Name*

Deal Name*

Deal Stage*

Deal Pipeline*

AllyConnect ID*

AllyConnect ID can be located in your account at https://connect.allydvm.com within Gearwheel > Practice Profile.

Practice Email*

Practice/Front Desk Phone*

Practice Website*

Enter the practice's website URL. If you are unsure, enter www.none.com.

Practice Online Pharmacy URL

Practice Address*

Street Address

Street Address Line 2

City

Postal / Zip Code

Country*

Country

US States*

State / Region / Province

Canada States*

State / Region / Province

Practice Address State Selected

Practice Management System*

Please note, if the practice PIMS is not listed, they are not eligible for this program.

Do you have a Fax number?*

If you do not have a Fax Number, one will be provided for you.

What is your Fax number?*

Provide the Fax Number that will be ported into Furscription to facilitate the program.

Fax number Provider

Practice Contact Person*

First and Last name only

Practice Contact Person's Email*

Practice Contact Person's Phone Number

Practice Administrator Name*

Identify the trusted administrator who will be the point of contact for Furscription onboarding and will manage all users.

Practice Administrator Email*

This email address should not be a shared email. It will be used for Multi-Factor Authentication and user password resets.

Practice Administrator Phone*

Please enter a valid phone number.

Accepted By*

First and Last Name Only

Repleni-Trac Checkbox*

Partnership*

Today's Date*

MM/DD/YYYY

MWI Account Number

Furscription billing is processed through MWI. Please locate your current MWI Account Number if applicable.

Agree to Terms

___________________________________________________________________

In order to start your account, you must read and agree to Furscription’s Terms and Conditions and Privacy Policy.

You have read and accept the Terms and Conditions and understand the Privacy Policy. You agree to the introductory rate of $75/mo for Furscription services and authorize Furscription to activate your account.*

Yes

You have read and accept the Terms and Conditions and understand the Privacy Policy. You agree to the introductory rate of $50/mo for Furscription services and authorize Furscription to activate your account.*

Yes