PHONE: 844-720-1115 | EMAIL: firstname.lastname@example.org
Phone number with area code
Address (include city)
Reason for calling: (We can add a drop- down box for quick choices such as needs immediate service, appointment related, information/pricing request, general message, etc.)
Other questions to be added:
Please include people to receive messages and any delivery requests in the “Contact Information” section.
Midwest Answer is hereby authorized to be my answering service and to act as my agent in all matters relating to answering, messaging, and
telecommunication services. I agree to the terms and conditions of service, and I agree to pay all charges as per invoice terms. By submitting this form, I acknowledge receipt of ASI Terms and conditions. I understand that my use of any service provided by Midwest Answer constitutes acceptance of these terms and conditions. I authorize Midwest Answer to verify the information given on this application and to receive and exchange credit information concerning this account both now and in the future. Provision of service is contingent upon credit approval. Midwest Answer requires a customer approved protocol in advance of service implementation or services cannot be provided.
I understand that Midwest Answer will charge me in advance of usage and that charges in excess of the monthly allowance may be required on a
periodic basis. I also understand that Midwest Answer may require changes to this agreement if the plan chosen does not match actual usage of the service. Midwest Answer reserves the right to suspend service at any time in the event of unpaid premiums or changes to the service agreement. Usage will be reviewed quarterly, and rates may be adjusted as indicated.
New or Current Patient?
Reason for calling: (We can add a drop- down box for quick choices such as appointment related, information/pricing request, general message, etc.)