PracticeIQ Snapshot – Practice by Numbers

Please provide your practice information below. After you click Submit, you will be able to schedule a time for the snapshot.

First Name(Required)

Last Name(Required)

Practice's Name(Required)

Email(Required)

Practice's Phone(Required)

Other Phone

Practice Management System(Required)

Other PMS (Unsupported)(Required)

Other PMS

Please enter your Practice management system that is currently not supported. We will contact you when we start supporting it.

Your Consultant/CPA Name

Please enter the name of your consultant who you are getting PracticeIQ through

Yes, I would like Practice by Numbers to access our server to install Practice by Numbers software and I agree to the Terms of Use.(Required)

I agree to the Terms of Use.

Yes, I am in an active consulting relationship with the above mentioned Consultant organization. I would like to allow access to all my data including patient health information (PHI) to my Coach.(Required)

I agree

Yes, I have an active Business Associates Agreement with the above mentioned Consultant organization.(Required)

I agree

Yes, I understand I can revoke access from the above mentioned consultant to view my data either myself on the Practice by Numbers website or by sending an email to support@practicenumbers.com(Required)

I agree

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Affiliate Referral Source

Hidden

Affiliate Referral Source Timestamp

Hidden

Initial HTTP Referrer

Hidden

Initial HTTP Referrer Timestamp

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Snapshot

Yes

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Referring Consultant

Hidden

Consultant Email

Hidden

Auto create ticket

Yes

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