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New Clinic Information

Clinic Name
Leave Blank. RxAssist Plus will fill this in.

Primary Contact Information
Administrative Login Name
First Name
Last Name
Confirm Email  
Password must be a minimum of 8 characters and must contain 1 capital letter, 1 small letter, 1 number and 1 special character (!,@,#,$,%,&,*, etc.) to be a valid password.
Confirm Password  
Clinic Address Mail Address (if different)
Address 1 Address 1
Address 2 Address 2
Address 3 Address 3
City City
State State
Zip Code Zip Code
County County
Phone Fax
Format 999-999-9999 Format 999-999-9999