Aeva Partner Program Enrollment

Aeva Partner Program Enrollment

Please complete this enrollment form to join the Aeva Partner Program & Network
Your Primary Contact Information

This information will be private and used for a primary point of contact at your practice.
Name*

First NameMiddle NameLast Name
Your preferred contact email*
example@example.com
Your preferred contact phone number*
Please enter a valid phone number.

Your Business Information

This information will be shared and publicly accessible in the Directory
Business Legal Name*
The legal name of the business. Referral commissions will be paid to your practice using this name.
Business Operating Name*
The business name you use when holding out to your clientele. Note: This can be the same as your legal name.
Business Email*
example@example.com
Business Phone*
Please enter a valid phone number.
Business Street Address*
Street address for your business
Business City*
City for your business
Province/Territory*
Province/Territory for your business
Business Description*
How you would like your business described to prospective clients.
Business Website (if any)
Please enter the URL for your business website.
Select your primary professional specialty*
Would you like the visibility for your business to be boosted?*
i.e. If Aeva offered you the option to increase the likelihood that your business is seen in the directory, would you be interested?
Which software (if any) do you use in your office for scheduling client appointments?*
If none, please enter "none".
Which software (if any) do you use in your office for submitting patient/client claims to insurance companies?*
If none, please enter "none".
Should be Empty:

Your Primary Contact Information