Orthodontist Registration AAO Informed Consent + Covid-19 Screening Questionnaire (Optional) Name* First Last Username*Your url will be based on the username like us.patientriver.com/o/username Orthodontist Office Name*No spaces, dash or special characters. Logo*Please choose your logo from your website. If you are using mobile phone, it is recommended to take screenshot of your website logo or background and crop it.Accepted file types: png, jpg.Email*THIS IS YOUR FRONT DESK OR OFFICE EMAIL. WHEN YOUR PATIENT COMPLETES THIS CONSENT, THIS EMAIL WILL RECEIVE PDF SUBMISSION. PLEASE MAKE SURE IT IS ACCURATE AND DONOT USE YOUR PERSONAL EMAIL. Enter Office Email Confirm Office Email Hide age / date of birth in the consent?*YESNOI confirm that the username and email address provided is accurate.*You would not be able to change email address / username, once your page is created.YESNOPayment Terms & Condition.*One time payment of $50 is required to use this service. This helps me to cover development, hosting server, email server and support expenses. This site is HIPAA compliant, all data is transmitted securely over SSL secure certificate. Patient data is not stored on the server. If you require signed BAA, there is additional one time cost of $100. All payments are non-refundable. If your payment is not received with-in 24 hours, your page will become inactive. If you require support or customization, it will be $70/hour. I agree to the payment policy. This iframe contains the logic required to handle Ajax powered Gravity Forms.