Note: If there is some information that you don't know, that's ok. Just fill in what you can and we'll get in touch with the doctor's office.

Please send Docpay information to:

Practice Name:
Name of person who handles patient financial arrangements at this office (if you know it):
Doctor's Office Address Line 1:
Doctor's Office Address Line 2:
Doctor's Office City:
Doctor's Office State:
Doctor's Office Zip Code:  - 
Doctor's Office Telephone:
Doctor's Office Email address:
Type of Practice:
How did you hear about DOCPAY?

In order to make sure you receive your payment plan for free, we need to know who you are:
Your Name:
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Comments or Questions (Optional):

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