Physician Web Solutions

Please provide the following information about your practice:
Street Address
City
State
Zip Code
Phone
Fax


If you have already purchased a domain name please provide the following information:
Domain name		(e.g. foxvalleyphysicians.com)
Purchased from		Name of company where you purchased from or the url (e.g. 1and1.com)
Login info
Password

If you have not purchased a domain name please provide 3 choices:
1st choice		(e.g. foxvalleyphysicians.com)
2nd choice		(e.g. foxvalleyphysicians.org)
3rd choice		(e.g. foxvalleydocs.com)


Please provide up to 3 email preferences for each physician.
Name of physician 1
email choice 1		(e.g. drcheryl@ foxvalleyphysicians.com)
email choice 2
email choice 3

Name of physician 2
email choice 1		(e.g. drteresa@ foxvalleyphysicians.org)
email choice 2
email choice 3

Name of physician 3
email choice 1		(e.g. naz@ foxvalleyphysicians.com
email choice 2
email choice 3

Name of physician 4
email choice 1
email choice 2
email choice 3

Support:

phone: 770-893-2797