Partner Signup Contact Information Doctor First Name * Doctor Last Name * HYD Contact (If different from above): HYD Contact Cell Email Practice Type (choose one) * Please select oneMDDODentistDCOD 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? Please select oneHalf down on the day of sign upremainder due in 30 days.Equally split out over the length of their plan (24or 6 months). UGA Financing: Username Password Do you approve HYD to finance a patient on a serviced plan? * Please select oneYesNo