Enrollment Form - Tridiuum

Welcome! To get started with Tridiuum ONE, please complete the enrollment form below.

Disclosures and Agreements: By submitting this form you agree to Tridiuum’s User License Agreement, Business Associate Agreement, Terms of Service and Privacy Policy.

Problems? Contact us at help@tridiuum.com for assistance.

Select your Tridiuum ONE Package*
First Name*
Last Name*
Email Address*

Email address is required to create your user account. We will communicate with you using this email address.
Phone Number*
Do you have an existing login to Tridiuum ONE sponsored through another organization?*
- Yes
- No
Please enter the email address you use for the other account
Do you treat patients?*
If you do not provide clinical services to patients change this to "No."
My NPI*
Enter your Individual NPI number (not the NPJ for your Group Practice.) Enter "N/A" if you do not have an NPI.
Check all that apply
- I am part of a group practice
- I have more than one location where I see patients
- We have more than 25 providers
We will contact you to set up additional users or locations if needed.
Organization Name*
Enter the name of your practice or organization.
Site Name*
The name of your primary location. It can be the same as your organization name provided above. This will be the user friendly name that prints on reports.
Address*
Site Street Address Site Address Line 2 Site City Site State Site Zip Code
Site Time Zone*
Comments
Enter comments or additional information you'd like to share with us here.
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Comments
This field is for validation purposes and should be left unchanged.