Support

SOAPware Priority Support Subscription Order Form

Priority support can be billed at $1000 per year or $100 Month. Please choose your billing method.

Please bill me yearly Please bill me monthly

Description QTY Unit Price Annual Total

SOAPware  priority Support /Per User* $0.00

General Information

*Physician:
*Person Placing Order:
*Email:
*Clinic Name:
*Clinic Phone: (xxx-xxx-xxxx)

Billing Information

*Street:
 
*City:
*State:
*Zip:
Phone:
Fax:

Shipping Address

Check to use Billing Information:

Street:
 
City:
State:
Zip:
Phone:

Payment Method

Name on Card
Card Type
Card #
Expiration Date (MM/YYYY)

Monthly Service Agreement

Please insert your initials in the “Initials” field below to indicate you understand and agree to be charged TWELVE (12) monthly installments, each charge totaling $0.00. The initial charge is to occur the first business day of this coming month; the last charge is to occur exactly ELEVEN (11) billing cycles after the initial charge. Intermediate charges are to occur the first business day of each month. By entering your initials in the “Initials” field, you electronically acknowledge the existence of this contract and claim responsibility for all charges associated with this service. At the end of TWELVE (12) months the contract is considered null unless specifically extended or stated otherwise.

Initials:

 

Additional Notes

If you don't wish to submit your credit card information via the internet you can print this page and fax it to SOAPware, Inc at 866-237-9073

*A user is defined as a doctor, physician assistant, nurse practitioner, or independently practicing nurse (i.e. Home Health Nurse or Therapist). Nurses (registered, licensed practical or nurse assistants) practicing directly in conjunction with a licensed practitioner do not require a separate license. Each licensed user can use products on more than one computer.