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:
Only $25/month per user billed annually.
Company Name *
First Name *
Last Name *
Email *
EMR/EHR Name
Mobile Number *
State *
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Job Title
Association Code
Contact Role
Authorized Signer
Date/Time
I accept the
DrFirst Backline Agreement and Terms of Service
*
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