Order Form

HIPAA-Compliant Telemedicine App

Telehealth Video Chat, Video Conference, Teleconference, Webinar


Monthly Pricing:

Contact Info

Contact Name:

Registration Email:


Business Name:

Business Address:

Your Current Website Address:

Logo: Upload Your Logo (limit 10MB):

No logo? No problem. We will put your company name at the top in a bold font. Specify below if you have a font preference.


Credit Card Number (AmEx, Visa, MasterCard):

Expire Month:

Expire Year:


Name on Card:

Billing Address for Card:


State:    Zip:

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Charges and future communication will be from Brazzell Marketing Agency, Inc.
Your local sales tax will be added if you are in a state that charges sales tax on software as a service. This includes AZ, CT, IA, LA, NM, MA, NY, OH, PA, RI, SC, SD, TN, TX, UT, WA, WV.
Please allow up to one business day for account set up.

SPAM CHECK: What is 1 plus 1?

No part of this website is intended to be billing advice.
The use of telemedicine apps may not always be billable to insurance.
is a brand of
Home Health Marketing