This form must be completed by the owner of the practice, and all fields are required.

Owner's First Name:

Owner's Last Name:

Owner's Email Address:

Owner's SMS/Texting Number:

Practice Name:

Practice Location Address (If you have multiple locations, please specify the location where this user is located, or if they require access to all locations):

Practice Website:

New User's Information

New User's First Name:

New User's Last Name:

New User's Email Address:

New User's SMS/Texting Number:

User's Physical Location (City and State):

Please select the user type:

Admin User
Has access to all of the dashboard apps and can create more users, but cannot change the budget for advertising or any financial obligations.

Operator User
Limited access to specific applications / functions only. This role applies to any one single location.

Billing User
This user has only access to billing app and can see all the transactions history in the dashboard.

What is the role of the new user?

Employee on payroll (Front-desk, In-house Marketing staff, In-house social media staff)

Practice Administrator

Partner (Does not work for the practice, but is an outside partner)

Contractor (Does not work for the practice, and provides outside services to the practice)

External Marketing Staff (Outside marketing staff, consultant, advertising company)

I verify that this information is accurate and all user accounts are subject to HIPAA laws.
Customer is expected to use PatientGain platform in accordance to TOS and BAA agreement. Customer must change all assigned passwords and security codes. Customer may not use “generic” user names, like “frontdesk”, each authorized staff at the practice must have unique logins, and there should be no shared logins. Customer must report any login breaches to PatientGain immediately. Customer is responsible for maintaining the user’s access. Customer cannot provide access to anyone outside of the USA. If a user accesses any of PatientGain’s services from outside USA, PatientGain will immediately revoke, with or without notice, any HIPAA compliance responsibility and may terminate account access immediately. Customer is responsible for maintaining proper, limited access to PII and PHI within PatientGain apps. Customer is expected and encouraged to ask questions and send any questions to PatientGain administrator – administrator@patientgain.com