Patient Stream Checkout - Patient Stream

Select The Plan Type(Required)

Kickstarter

Accelerator

How Many Days Between Initial Payment And Subscription Starting?(Required)

Zero, Subscription Starts Today

30 Days After Today

60 Days After Today

90 Days After Today

Initial Payment Due Today(Required)

Leave this as zero if they are doing a month to month agreement

Monthly Recurring Price (Month to Month)(Required)

Name On Card(Required)

First Last

Billing Email(Required)

Clinic Name(Required)

Clinic Phone(Required)

Clinic Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card

(Ignore Me)

Ignore this field. It will just add up all your numbers but it isn't necessarily what will be charged.