Electronic Office Product Registration

Welcome to the Electronic Office Registration Form.

Continued use of Electronic Office requires Monthly Authentications, and once your free trial period has expired, payment of monthly Patient Record Access Fees. In order to provide you with your authentication codes, your copy of Electronic Office must be registered with Medigrate Corporation, and Medigrate must have a signed copy of your Patient Record Access Fee Agreement. This agreement can be printed from your Organization Information form, in the Data Maintenance and Reports module.

Please provide us with the following information about your medical practice/organization, about yourself, about your computer systems, and about the copy of Electronic Office you are registering. Medigrate Corporation never makes its mailing lists or customer information available to other parties. For additional information about our privacy practices, click here.

Required fields are indicated with red captions. This form cannot be submitted without all required fields completed.

Step One -- Tell us about your medical practice/organization:

Practice/Organization Name (Required):

Address 1 (Required):

Address 2:

City (Required):
If outside of USA, please include Province/Country.

ST (Required):

Zip (Required):

Time Zone:

Phone number (Required):

Facsimile number:

E-Mail Address:

Primary Specialty:

Number of Office Locations:
Number of Providers in Your Practice:

Step Two -- Tell us about yourself:

Contact Name (Required):

Title:

Medigrate.com includes a private Customers Only site which includes product downloads and upgrades, and an authentication code request form. With time, other useful information for our Electronic Office customers will be added. The site is limited to only those customers with valid Usernames and Passwords on file. You can register your Username and Password now, or contact us at 1.877.Medigrate with your username and password once you become a registered customer. Access to the Customers Only site is provided through the login button at the top of the Electronic Office home page.

Username (4-15 characters):

Password (4-10 characters):

Confirm Password:

Step Three -- Tell us about your computer system(s):

Workstation operating system:
(If mixed, then select the most common)

Network server operating system (if applicable):

Number of computers
on your network (if applicable):

Step Four -- Tell us about your copy of Electronic Office:

Serial Number (Required):
Must be entered EXACTLY as it appears
in any Electronic Office About Box, including
UPPER-CASE and lower-case letters, and hyphens

Version
(Required):

How do you wish to receive your
Monthly Authentication Codes (Required)?

Pricing Option (Required)?

How did you obtain your copy of Electronic Office?

Step Five -- Tell us anything else you think we should know:

Place a check here to receive e-mail notices about future updates and releases.

Miscellaneous Comments, Questions, or Suggestions:

Privacy Practices