VirtualCare Assessments Registration Form (existing VirtualCare users only)

Your Information

First Name

Last Name

Contact Email (same email as used for VirtualCare registration)

Name of Clinical Site (Business Entity Name)

Phone

Professional Designation Number

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Master Services Agreement

Required: By checking the box, I agree to be bound by the terms and conditions set out in your existing Master Services Agreement.

Yes

Required: By checking the box, I have read and understood Think Research’s terms and privacy policy.

Yes

Packages and Terms

Please select your packages from the following options.

Discount available: Order two or more packages and save 50% off activation fees and $5/month off each additional package subscription.

Intake Package (Consent to Service, Consent to Disclose, Intake forms) $18/month

Mental Health Package (Patient Health Questionnaire PHQ-9, Generalized Anxiety Disorder GAD-7 assessments)
$12/month

Invoice Package (Invoicing, Receipt forms)
$12/month

Fees: Customer will be billed at the applicable rate(s) plus a one-time activation fee of $50/package minus applicable discounts. Taxes applicable.
Payment Frequency: Monthly recurring. After your initial payment, you will be billed on the same day as your regular VirtualCare license payment.
Agreement Term: 12 month (1 year) term commencing on date of form submission

Total packages number

Intake package number

MH package number

Invoice package number

Total one-time revenue

Total Recurring Revenue

Total Revenue

Payment Information & Terms

Name on Card

Card Number

MM

YY

Code

Required: I authorize Think Research to charge my credit card for use of the Services. I understand that Think Research uses a third-party service provider to process all payments and will have access to personal information needed to perform their functions, but may not use it for other purposes. I also understand that all credit card information will be collected and stored on a secure platform by the third-party service provider.

I understand

VirtualCare Assessments Registration Form (existing VirtualCare users only)

Your Information

Master Services Agreement

Packages and Terms

Payment Information & Terms

Please click "Submit" to complete your registration.