MMS Online Clinic Application CORPORATE DETAILSCorporate Name*Business Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Type of Business*CorporationPartnershipOtherType of Business - Other*Please provide detailsDirector 1 Name* First Last Director 2 Name (Optional) First Last Primary Contact Name* First Last Primary Contact Phone*Primary Contact Email* Are you a dispensary?*YesNoConservative estimate of patients per weekCan you list the top 5 Licensed Commercial Producers you prefer to use?Licensed Producer Name 1Licensed Producer Name 2Licensed Producer Name 3Licensed Producer Name 4Licensed Producer Name 5APPLICATION PROCESS Would you like MMS to process your payments?*YesNoWould you like MMS to perform your customer service?*YesNoWill we be answering the phone?YesNoWill we be contacting patients for renewals?YesNoDescribe Other Customer Services RequiredWill you be using our online digital application form?YesNoWould you like it to appear as if the Application Form belongs to your organization?YesNoUpload your logo here:Your logo can be any of these formats - jpg, png, gif, pdf Drop files here or Accepted file types: jpg, png, gif, pdf. Please upload your application forms for our review.Your form can be any of these formats - jpg, png, gif, pdf. Drop files here or Accepted file types: jpg, png, gif, pdf. If applicable please provide URL of your existing online application form(s) for our review.Customer Service Email* Customer Service Phone*Form Confirmations & NotificationsWhen a client submits one of our forms we offer extra services to enhance your client communications as customized Confirmations and Notifications. These services are explained here with samples and input boxes where you can add your custom info/messages. Confirmation Page (required)This page displays to the client after they click Submit. Here we can provide a custom message about what to expect next. <-- Start Sample Confirmation Page --> Thank you! Your application has been received securely. One of our representatives will be in contact with you within 2 business days. Here is what to expect in the coming days: 1) You will be contacted to book a virtual consult with one of our trusted medical professionals. 2) You will be emailed instructions to set up your online doctor visit. 3) You will meet with your assigned doctor and if approved, you will be granted your prescription and medical cannabis card. If you have any further questions please feel free to email us at firstname.lastname@example.org. or call 1.866.000.0000. YourClinic.com - (link to your website) <-- End Sample Confirmation Page -->Enter your custom Confirmation Page message here:Confirmation Email (optional)This email is sent to the new client after they Submit the application form. Commonly referred to as the "Welcome Email" this can be customized to provide information and/or further directions. <-- Start Sample Confirmation Email --> Thank you! Your application has been received securely. One of our representatives will be in contact with you within 2 business days. Here is what to expect in the coming days: 1) You will be contacted to book a virtual consult with one of our trusted medical professionals. 2) You will be emailed instructions to set up your online doctor visit. 3) You will meet with your assigned doctor and if approved, you will be granted your prescription and medical cannabis card. If you have any further questions please feel free to email us at email@example.com. or call 1.866.000.0000. YourClinic.com - (link to your website) <-- End Sample Confirmation Email -->Enter Your Send From EmailThis is the email address the client will see as "Sent From". Enter Your Send From NameThis is the Name the client will see as "Sent From" Enter Your Subject LineThis is the Subject Line the client will see in the email. Sample: Welcome to YourClinicEnter your custom Confirmation Email message here:Notification Email (optional)This email is generated after the form is submitted and can contain any data fields included in the form. Generally used as a notification to your staff that an application has been submitted. <-- Start Sample Notification Email --> Name: Joe Smith Phone: 123 456 7899 Mobile: 123 456 7899 Email: firstname.lastname@example.org Preferred Contact Method: Phone: Email: Both: x Best time to contact: Morning: Afternoon: x Evening: Primary Medical Condition: Chronic Pain Address: Street Address: 123 Main St. Address Line: Apt. 222 City: AnyTown State / Province: Ontario Postal Code: E1E 1E1 Submit Date: 06/22/2017 <-- End Sample Notification Email -->Send Notification To EmailThis is the email address the Notification Email will be sent to. Separate multiple emails with a comma.Preferred Notification Email FieldsEnter the desired notification fields here or just type USE SAMPLE. This email is to be used as a summary/alert to your Admin/Staff/Managers to advise an application has been submitted. This notification is not designed to send all client data, that is done via other secure methods.Save and Continue Email (optional) All of the MMS forms have a "Save & Continue" function so the client can save their partially completed form and return later to complete & submit. As our forms are quite extensive often the client will need to locate more information. If they select "Save & Continue" their form is saved and the email below is sent to them with a link to return to their form later. If you would like to change the wording of this email please provide details. If desired this email can be CC'd to your staff so you can see when this feature is used and/or contact the client to inquire if they need support. To receive a copy of this email provide an email address(s) below. <-- Start Save and Continue Email --> Thank you for saving --the form title appears here --. Please use the unique link below to return to the form from any computer. -- saved form link appears here -- Remember that the link will expire after 30 days so please return via the provided link to complete your form submission. <-- End Save and Continue Email -->Change Save and Continue Message Wording To:Send Copy of Save and Continue To EmailThis is your email address a copy of the Save and Continue Email will be sent to. Separate multiple emails with a comma.Extra InformationJust in case we missed something or you have extra data to include with your application please provide it here. Save and Continue Later This iframe contains the logic required to handle AJAX powered Gravity Forms.