Our 5 minute sign up is easy and allows you to
instantly start legally providing discounts to your patients.
Start the process below.

Please fill out the form below to get started with creating a username and password.

Business Information

Business Name*
Contact Name*
Title/Role*
Address*
City*
State*
Zip*
Phone*
Email*
Fee Schedule*

Please copy/paste your fee schedule here. Why do we require this? By law, we need to have your fee schedule on file.
How did you hear about us?
Affiliate Name*

Payment Information

Amount $99 per month subscription
Payment Card Number*
Expiration Date*
Click Here To Copy Business Information
Card Holder Name*
Card Holder Address*
Card Holder City*
Card Holder State*
Card Holder Zip*

User Account

User Name*
Check Availability
Password*
Confirm Password*
I read and agree to the to the Patient Options HIPAA Business Associate Agreement found here.