Microsite TeleHealth Implementation Form

If you are ready to sign up for Microsite TeleHealth, please use this form to provide your practice information.

If you are not ready to begin or simply want more information, please complete the Learn More Request Form at the Teledentistry Request Form tab under Virtual Solutions tab above.

For Implementation, you only need to complete this request once per practice. You will need to identify ONE admin user for your practice. Additional users will be created once Microsite Telehealth is set up for your group.

Within 24 hours of form completion, you will receive an email from [email protected] with your username, log in instructions and a getting started guide.

Filling out this form means your practice would like to set up an account with Microsite TeleHealth today.

Practice Name*

Patient facing practice name. Patients will see this name in Updox.
Practice Address*
Practice City
Practice State*
Practice Zip Code*
Practice Phone*
Admin User*
First Last
First and Last name of the administrative contact for this implementation. This individual will be set up as an Administrator for your Updox account.
Admin User Email*
Admin User Contact Number*
What is the best number to reach the above contact?
Anticipated number of provider users (MD, DO, NP, PA, ONLY)*
When will you be ready to see patients via telehealth?
- Immediately
- Within the next week
- Within the next month
- Unknown

Microsite TeleHealth Implementation Form

Microsite TeleHealth Implementation Form

WHAT WE OFFER

MICROSITE HEALTH

EDUCATION

SUPPORT