Complete the Registration Form
Please select a practice type below and then click the 'Enroll Now' button to open the online registration form. Complete the information in the fields provided and press the submit button.
Check Your Email
You will receive two emails from firstname.lastname@example.org. The first confirms that we received your online registration, and provides a copy for your records. The second email includes either a consent form or provider agreement that requires an authorized signature. (If you don't see it, check your junk mail or give us a call.)
Fax Back the Appropriate Form
Print and complete the appropriate form. Then sign it and fax it to us with a voided check.
Watch for the Red Box and the Welcome Email
Your red membership kit will arrive in about a week with patient brochures and a brochure holder. You will also receive an email to set up your login for the Lending Club web site.