Telehealth Backline Consent Form – Part 1 of 3
Telehealth Backline Consent Form
Backline Telehealth Registration
Step 1 of 3
Get Started with Backline for Telehealth: $300/user per year.
Company Name *
First Name *
Last Name *
Email *
EMR/EHR Name
Mobile Number *
State *
AL
AK
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
NE
NH
NJ
NM
NV
NY
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
Job Title
Contact Role
Authorized Signer
Date/Time
I accept the
DrFirst Backline Agreement and Terms of Service
*
Continue