WelSpot Provider Enrollment Application

Practice Enrollment Application

Please tell us more about your business to get started
Practice Information
Legal Practice Name *
DBA Name of Practice *
Business Address *
Business Address 2
Business City *
Business State *
Business Zip Code *
Business Email *
Business Phone Number* *
Practice Speciality *
Ownership Type *
Federal Tax ID *
Year Business Established *
Medical License Holder Name *
Medical License Number *
Medical License Date

Month Day Year
Owner Information
First Name *
Last Name *
Job Title *
Home Address *
Address 2
City *
State *
ZIP Code *
Mobile Number *
Business Email *
Office Phone *
Owner Social Security Number *
Owner Date of Birth *

Month Day Year
Administrative Contact (Office Manager)
Name *
Email *
Phone Number *
Banking Information
Account Holder Name
Bank Name
Routing Number
Account Number
Account Validation
Are you currently offering Financing? *
How did you first learn about WelSpot? *
Rep ID / Promo Code / Referral Code
If Other Where Did You Learn From WelSpot?
Consent *

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Practice Information