Secure Dental Forms - Online and offsite patient form service. HIPAA compliant.

Thank you for signing up for our basic service. This form will calculate your initial cost, collect some basic information so we can begin setting up your account.

Practice Name	*
Dr Name	*
Office Contact Name	*
Email Address	*
Web Site Address	*
Office Address	*
City	*
State	*
Zip	*
Phone	*
Fax	*
Practice Management Software	*
Do you know of any colleagues that might be interested in Secure Dental Forms?
Type of Forms requested	PDF Web
Fee of $349 covers converting 5 of your forms to PDF, each additional form will be $75 per form.
Bill Me Cost is $49 per month, may be paid annually	Monthly Annually

PRICING
Service $49 per month recurring charge or annual billing depending on your preference above.	0
Forms	0
Total	0
If you choose PDF forms, $349 will be charged today for forms setup. $49 will be billed on 6/26/2024 (60 days from today) if you selected Monthly. If you selected Annual Billing then $588 will be billed on 6/26/2024 (60 days from signup date).
* By checking this box and submitting the following information to Secure Dental Forms you agree to accept these charges. Please note that the company name on your credit card statement will be Advanced Automation, Inc.
Your Name (signature)	*