*Name of Person Submitting Form:

*Client/Clinic/Organization Name:

*Address:

*City:

*State:

*ZIP/Postal Code:

*Phone:

Fax:

*Email:

Authorization

The client mentioned above authorizes the AHDL to assign login information to enable secure access to client’s account within WebSuite client portal. Client may choose to change the password by going to update profile page upon log in.

The client/clinic/organization submitting this form is responsible for security of the login information including providing access to other individuals within their employ.

*Required field