Self-serve Account Setup Form

Set up your plan

Complete this short form to confirm your selected plan and signer details.
Selected plan
Commitment type
Monthly Fee
Included Scan
Helper - do not delete
Extra Scan Fee
Institution Name*
This will appear on the portal and patient communications
Country - Outside North America? Contact us.*
Full Name*
Title*
Email*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Zip / Postal Code*

Finish setting up your account

Please complete the form below and upload any required files so we can set up your MaskFit AR account. Once we have received all the required information, we’ll notify you as soon as your account is ready.
Institution Details
Add locations only if you use MaskFit at more than one site. For multi-location accounts, you can manage user access by location and view location-specific statistics.
Check here if you would like us to include a unique QR code and corresponding link (patient-initiated profile completion from your waiting area, referring physician's office, or welcome email)
The Re-engagement Program: reconnect with patients who've stopped ordering their CPAP supplies.Providing MaskFit on our e-commerce site (integration and non-integration workflows available)Integration with our CRM software
Which CRM are you using?
Upload Logo
Your logo will appear in the MaskFit portal and in communications sent to patients.
Cancelof

Payment Amount*

USD