1 Practice Info 2 Overview 3 Purchase 4 Confirmation Practice / Clinic Information Legal Business Name * DBA Name Contact Name * Phone * Business Phone * Locations * Email * Address * Website * How did you hear about us? * Working with sales agent? —Please choose an option—Julian ChacinKelly Flores Continue → Clinic Overview Areas of focus * Functional MedicineNutrition / HolisticWellness centerChiropracticMedSpaOther Monthly patient volume * Use lab diagnostics? * YesNo Diagnostic tools (Optional) BloodworkBiocheckMenlaScanS-Drive Hair Offer supplement protocols? * YesNo Why Intrascan360? * ← BackContinue → Payment & Purchasing Intent Plan to purchase immediately? * YesNoEvaluatingOwn a device already Name of device Payment option * UpfrontFinancing ← BackContinue → Final Confirmation I certify that all information provided is accurate. * I acknowledge I am authorized to make purchasing decisions. * I accept the BAA and Terms & Conditions.* Digital Signature * Date * ← BackComplete Registration →