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Contact Information


Doctor First Name *

Doctor Last Name *

HYD Contact (If different from above):

HYD Contact Cell

Email

Practice Type (choose one) *

Practice Street Address 1 *

Practice Street Address 2

Practice City *

Practice State *

Practice Postal Code *

Practice Phone *

Practice Email *

Your Merchant Virtual Terminal Log-In:

URL for online virtual terminal *

Username

Password

If a patient decides to pay by check, whom shoudl they make it out to?

Deposit slip info

Bank Name

Account to be deposited into

Delayed Payments

Do you approve HYD to accept a delayed payment agreement w/ ptnt
Yes     No

If yes, what terms are acceptable to you?

UGA Financing:

Username

Password

Do you approve HYD to finance a patient on a serviced plan? *

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