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  • Patient Loyalty Builder Intake form

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  • Do you have multiple locations for this practice?*
  • Do you currently have a website for your practice?*
  • Do you have a logo for your practice?*
  • Upload a File
    Cancelof
  • Please select your desired discount plan level:*
  • Where would you like us to send your in-house plan welcome kit? This includes a start-up guide, and plan marketing materials. *

  • Authorization Agreement of Monthly Direct Deposit

    When a patient enrolls in your in-house plan, the membership fee is collected through an online payment portal. We need the below financial information so we Careington (our licensed insurer) can pay you your distribution of the membership fee.

  • Account Type:*

  • I (we) hereby authorize CAREINGTON INTERNATIONAL, to initiate credit and, if necessary, debit entries and adjustments for any credit entries in error to my (our) account, at the depository Financial Institution name above, and to credit or debit the same from such account. I (we) acknowledge that the authority will remain in effect until I have (or either of us) cancelled it in writing and that the origination of ACH transactions to my (our) account must comply with the provisions of U.S.law.

    Note: Careington commissions are released once an agent's commission reaches a minimum of $25 and commissios will be paid on or around the 15th of the month for the prior month.

  • Should be Empty: