General Information

Owner First Name *

Owner Last Name *

Owner Phone *

Owner Email *

Address

Street Address *

City *

State *

Country *

Country

Postal Code *

Do you have a website? *

Yes

No, but I have a domain purchased

Website Domain

Do you have a logo and brand colors? *

Please select one

List your brand color codes or share a branding kit link.

Upload A High Quality Logo (Optional)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Do you need a HIPAA-compliant CRM with sales pipeline, automated SMS and emails (payments, refills, stale leads, patient follow-ups)? *

Please select one

It is highly recommended that you have a CRM and/or an EHR where you manage your patients if you are a clinic providing medical services or if you would like to access customer informaiton to market to. If you are not a clinic holding internal lisences and without access to PHI you may not need a CRM and/or EHR.

What CRM and/or EHR are you using?

Do you have a medical director? *

Please select one

A medical director is required to access Protected Health Information (PHI) and is an additional expense agreed upon between the clinic and the director. Medical oversight can range from hundreds to several thousand dollars monthly. By choosing to use our clinical team when selecting "No, I want to use your team" you understand that you are not recognized as the clinic for the patient of record until you obtain a license and manage medical oversight for patients receiving treatments in a given state. You will be compensated for your sale of access to medical treatment, not for the treatment itself.

Would you like to use our practitioner network to access 50 states as you grow? *

Please select one

How will you utilize our practitioner network? *

Please select one

Please explain how you will use our practitioner network network. Share any service, state, and medication specific details in you'd need our team to manage.

Will you use our prescription services or your own pharmacy relationships? *

Please select one

Please provide pharmacy details.

Medical Director First Name

Medical Director Last Name

Medical Director Email

Do you have any additional details to share that weren't covered in this document such as 3rd party integrations you would need to connect, unique details of your business, etc.?

Please select all services you intend to use from Aide Softwares. Selecting the options below does not commit you to purchasing these services; a signed agreement is required to formalize any commitment. *

Branding (Logo & Branding Kit)

Website - Ready To Launch Website

Custom Website - Requires Seperate Quote + Development Time

Use Our Medical Team

Custom Integrations

Branded Emails, SMS, and Automations (Includes CRM Access)

Branded Emails, SMS, and Automations (No CRM Access)

Complete Software Set-up (Set-up Software and Integrate with Existing Website)

Just Software Access - No Extras or Setup

Other

Please explain "other" needs:

Payout Information

Vendor/Company Legal Name *

DBA, If Applicable

Account Type *

Account Number *

Routing Number *

Text Verification Information (A2P registration)

Friendly Business Name (what people call you) *

Official Business Name *

Official Business Email Address *

Official Business Address *

For A2P 10DLC registration, you must provide your Tax ID / EIN *

Business Type *

Stock Ticker & Exchange (if Public)