Services to be Added *

Fees apply according to SpringCharts licensing type. Discuss with your account manager. Check the services to be added.

Telehealth Provider with Video Visits & Secure Chat

Telehealth Staff with Secure Chat

Phone

(###)

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Ordered By *

First Name

Last Name

Direct Phone *

(###)

###

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Confirm Enrollment Request *

I am authorized to make this request on behalf of the practice named above and authorize Spring Medical Systems, Inc. to charge my method of payment on file for associated fees.