Secure Form

Secure Forms Order for Existing Customers

By approving this order, the customer agrees that:

This order covers the one-time fee for building your secure form(s).
Build timelines typically require two weeks from the time we receive your completed order form (not the quote form).
Rush orders (if possible) may incur an additional cost added to the quote.
Bugs and errors in form design are fixed at no charge. Any updates or changes to the form are $50/hour or $150/hour depending on complexity.
Any bugs or errors (e.g., typos, layout mistakes, or functionality issues) caused by our development team will be fixed at no charge.

*Edits and adjustments include anything added, edited, moved or removed from the first draft of the web form and PDF draft.

*Bugs and errors include typos, layout mistakes, and functionality mistakes that were created in error by our development team during the form build process.

2. Please select add-on features

Routing of completed form PDFs into your company’s content or document management system ($150/hr, average 2-hour setup)

Allow non-Mediprocity users to retrieve completed forms or results. ($20 setup, $8/month for 1000 messages)

Additional Mediprocity user account(s) ($10 each unless you have existing contract). How many?

Allow a user to receive a copy of their submitted form (no charge)

Allow a user to send a copy of a completed form to a fax number (fax charges apply / $100 setup fee + charges to port a fax line)

3. Please provide name of person approving this project:

4. Order authorization by customer

Signature:

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Date

Please print name:

Other Customer Comments:

Software as a Service Agreement

Your account has already signed off on the Mediprocity Secure Forms agreement as software as a service "Agreement".

This agreement may be found with your first order with Mediprocity. You may review the agreement on your signed version. Should you need a copy please let our support team know.

support@mediprocity.com

Customer Signature

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Name:

Title:

IN WITNESS, WHEREOF, the parties have executed this Agreement on the Effective Date above written.

Customer’s signature constitutes acceptance and execution of this agreement.

Date Executed:

I accept the legal terms and conditions