On the form below, we will ask you for the information we need to set your Practice up as a Merchant in our system. However, we will need you to complete a questionnaire so that we complete your financing web site. Please make sure you return that form as soon as possible so you can get started. Please note: We will process your first monthly subscription fee of $575 when we receive your enrollment. However, you will have 30-days to cancel your subscription and avoid any future charges. If you do not cancel, you will be locked in to the subscription for a period of 6 months from the date of your enrollment. All charges you see on your statement will be from Credit Technologies. Thank you!