Agent Register - Ease Placement

Company * (If not affiliated with a company, enter your full name)

Mailing Address *

First Name *

Last Name *

Email Address*

Phone No. *

Username *

Password *

Re-type Password *

Location Coverage (optional)

Indicate the specific coverage area you aim to serve. Providing this information is crucial as it ensures that patient intake broadcasts are received with precision, aligning with the specified location you have identified. This enables a more effective and targeted response to patient needs within your designated service area.

To add a zipcode, just enter the zipcode value and press enter. You can delete them by clicking on the close icon or by using your delete button.

City	ZipCode	State	Action
No location selected

I hereby agree to the Terms of Service and have read or acknowledge our Privacy Statement.

I agree to the terms of the E-Sign Act Disclosure Agreement. I acknowledge that by checking this box, I consent to the use of electronic records and signatures in place of physical documents, and that I have read and agree to the terms outlined in the E-Sign Act Disclosure Agreement.

I agree to the terms of the Uniform Electronic Transactions Act (UETA) Agreement. By checking this box, I consent to the use of electronic records and signatures in place of physical documents, and I acknowledge that I have read, understand, and agree to the terms outlined in the UETA Agreement.

I agree to the terms of the Business Associate Agreement (BAA). By checking this box, I consent to the use of electronic records and signatures in place of physical documents, and I acknowledge that I have read, understand, and agree to the terms outlined in the Business Associate Agreement.

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Location Coverage (optional)

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