Wireless Contract Agreement

This form authorizes InPractice to sign up your practice/business for the wireless discounts offered in the Group Purchasing Organization. By filling out this form, you give InPractice the control to engage the Wireless Services Contracts for your practice/business.  A PDF copy can be downloaded here.

If you are unsure or do not know your company entity code, fill out the rest of the form to the best of your ability and we will look it up and contact you within 48 hours.

Thank you


* Indicates required fields

Entity Code:*
Company:*
Company Address:*
EIN:*
Name:*
Title:*
E-mail:*
Website:*
Office Phone:*
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Mobile:
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When is the best time to contact you:
Select Carrier(s):*
Describe your practice/business:
Type the characters you see here: