MD-HQ New Practice Details

Please fill out the form below to provide us with the basic details we need to get started. We'll follow up with you once we have your server up and running

Practice/Practitioner Detail Your Answer Notes
Practice Name Your full practice name (or your full name if you operate under your name)
Practice Address 1
Practice Address 2
Practice City
Practice state/Province
Practice Zip/Postal Code
Practice phone
Practice fax If you'd like a new integrated fax line just provide the 3 digit area code you'd prefer
Practice URL
Practice Email This is the general address for your practice, i.e.
Practice EIN Number Can also be your SSN if you do not have a EIN
Practice NPI This is used for generating HCFA 1500 forms

Your First Name  
Your Last name  
Your Title Prefix I.e., Dr., Mr./Ms., [nothing]
Your title Suffix I.e., MD, DO, CNP, RN, LAc, ND, DC, etc.
Preferred Username Note: should be longer than 6 characters
Personal Email
Note: This must be a PRIVATE email (you must be the only person who can access this account). We may also use this email address to send announcements to keep you updated about new features and events.
Your NPI Number Your prescriber ID, if applicable (medical practitioners only, not required)
Your Medical License Number If appliable (medical practitioners only, not required)

Preferred EMR URL Must be a subdomain of MD-HQ (i.e.
Preferred Patient Portal URL Must be a different subdomain of MD-HQ (i.e. Leave blank if you don't want the portal

Do you need us to import data? Do you have existing medical data to import from another electronic system?
Do you Need custom forms? We can convert custom patient forms, but we offer a discount if you do not require custom questionnaires (other than consents). You may also select from our existing forms library.
How did you hear about us?
Tell us about your users