Dealer Inquiries

Please submit the form below so that we know that you are interested in becoming a reseller for Visual Practice and can send you a kit! If you would like to apply to our Authorized Reseller Program and have Word 2000, download this document, read it, and fill out the form and return it to us by Fax, E-Mail or Postal Mail.

Please note that items colored red are required to be filled out.  We cannot process the form without this minimum information. 

Name

E-Mail

Company

Position

Address

City

Province

 Postal Code

Phone
include area code

Fax
include area code

URL

Areas of Interest
 Patient Data Management
 OHIP Billing
 Medical Office Management
 

Primary Business Focus
 Retail Sales
 Wholesale Distributor
 Value Added Reseller
 

Company Description

Company Size/Sales Value

 Please have a representative phone me.

Comments:

 

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Last Updated: Thursday, October 30, 2003 01:38 PM