Boston Cognitive Registration Form

Boston Cognitive Registration Form

New to Boston Cognitive? Complete this form to register your practice and submit your signed agreement. After registration, our team will provide you with a secure payment link to purchase your initial assessment package(s).
Practice Information
Practice/Organization Name
Legal business or facility name (For solo practices, enter your registered business name such as "Smith Family Medicine" or "John Smith, MD, PC")
Practice Provider Identifier
Organization/Group Practice national healthcare provider registration number, e.g., NPI for United States
Practice Type

Other
Specialties

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email

Confirmation EmailEmail address used for administrative communications (billing, contracts)
Review and Accept Agreement
By signing below, I confirm that I am authorized to enter into this Software as a Service (SaaS) Agreement on behalf of my organization and agree to Boston Cognitive's Terms of Service. I understand that after my initial package(s) purchase, my payment method will be automatically charged monthly for additional package(s) of the same type as they are used. I also understand that a HIPAA Business Associate Agreement (BAA) will be provided and must be mutually signed before entering any patient data.
Salutation
Professional or courtesy title
Name

First NameLast Name
Credentials
Professional degrees and certifications
Title/Role
Primary professional position
Date

YearMonthDay
4 digit year, 2 digit month, 2 digit day
Should be Empty:

Boston Cognitive Registration Form

Practice Information

Review and Accept Agreement