SAOE Group Enrollment (2 to 10 Members)
Please Note: You will need to allow pop-ups and redirects to use this form.
Step 1: Fill out the enrollment form below. Once you submit this form, you will be redirected to an AffiniPay payment page if paying by credit card.
Practice Name:
*
Practice Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Locations:
*
Number of Doctors at Practice
*
Practice Phone Number:
*
Please enter a valid phone number.
Practice Contact Name for Payment:
*
Practice Contact Email:
*
Number of Members for Group Enrollment:
*
Upload an Excel Spreadsheet with each member's name, title, email, & phone number -OR- use the boxes below to provide member information. (Please note: Cell phone numbers provided may be used to text membership and meeting updates.)
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Member #1 Name
First Name
Last Name
Member #1 Title
Member #1 Email
example@example.com
Member #1 Phone Number
Please enter a valid phone number.
Member #2 Name
First Name
Last Name
Member #2 Title
Member #2 Email
example@example.com
Member #2 Phone Number
Please enter a valid phone number.
Member #3 Name
First Name
Last Name
Member #3 Title
Member #3 Email
example@example.com
Member #3 Phone Number
Please enter a valid phone number.
Member #4 Name
First Name
Last Name
Member #4 Title
Member #4 Email
example@example.com
Member #4 Phone Number
Please enter a valid phone number.
Member #5 Name
First Name
Last Name
Member #5 Title
Member #5 Email
example@example.com
Member #5 Phone Number
Please enter a valid phone number.
Member #6 Name
First Name
Last Name
Member #6 Title
Member #6 Email
example@example.com
Member #6 Phone Number
Please enter a valid phone number.
Member #7 Name
First Name
Last Name
Member #7 Title
Member #7 Email
example@example.com
Member #7 Phone Number
Please enter a valid phone number.
Member #8 Name
First Name
Last Name
Member #8 Title
Member #8 Email
example@example.com
Member #8 Phone Number
Please enter a valid phone number.
Member #9 Name
First Name
Last Name
Member #9 Title
Member #9 Email
example@example.com
Member #9 Phone Number
Please enter a valid phone number.
Member #10 Name
First Name
Last Name
Member #10 Title
Member #10 Email
example@example.com
Member #10 Phone Number
Please enter a valid phone number.
Do you plan to pay by credit card or check?
*
Credit Card
Check
Please click the button below to submit your group enrollment form.
You will then be redirected to Step 2: Submitting payment.
Submit
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