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PatientScout - Service Agreement

This Agreement, which takes place on the below (effective date) is by and between Smart Med Sites, Inc., dba PatientScout (hereafter "PS"), having its principle place of business at 475 Gate 5 Rd, Suite 107, Sausalito, CA 94965 and the below (Practice Name, hereafter "Client"), with its principal place of business listed below.

Effective Date *
/
/
MM
DD
YYYY
Date of PatientScout Service Agreement 		  Practice Name *



Client Information

Dentist Name *
           
Title
First
Last
Suffix
  Practice Phone Number *

- -
###
###
####
 
Office Contact *

  Current Web Site

If you don't currently have an existing website, just leave this blank.
Practice Address Information *


Street Address

Address Line 2

City
State

Postal/Zip Code
Country
 
Terms

1. Fees and Payment: Client agrees to pay the One Time Set-up Fee and at least One Monthly Lease Fee based on the terms specified in the "Lease Information" section below.

2. Contractual Agreement: Client will pay the Monthly Lease Fee for the service and receive 4 qualified leads per month. Qualified Leads are defined as new prospective patients contacting Client by phone, email, or website contact form(s).

3. Guarantee: In the event Client does not receive at least 4 qualified leads, the next month's service will be provided at no charge.

4. Termination: This Agreement may be terminated by either party, at any time, with a written thirty (30) day notice from either party.



Lease Information

* The PatientPortal™ lease includes a 1-time $699 setup fee and a $299 monthly lease fee. The monthly lease fee starts 60 days after setup fee (2 months free)!



PatientScout Set-Up Meeting

Please let us know a convenient time to go over some simple set-up details.

Preferred Date *
/ /
MM
DD
YYYY
  Preferred Time *
: :
HH
MM
AM/PM
 
Current Dental Practice Email
This is your email address you use currently.
  Do You Want New Patient Leads Sent to This Address?

Yes No
 
Time Zone *
Pacific Mountain Central Eastern


Digital Signature

Authorized representative has executed this Agreement as of the Effective Date.

Authorized Representative of Customer: *




Click here to view this form as a printable pdf that can be faxed to our office.

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