What is Innexus? > Get Started > Sign-Up Now Sign-Up: Innexus Website Program Please complete the following information to sign-up for an Innexus website. Upon completion of this online form, you will receive a confirmation email and your website will be placed into production. Practice Name * Website Contact (Full Name) * Website Contact Email * Practice Owner(s) * Practice Doctor(s): If applicable, please put them in the order you wish them to appear on the website. Address * City * State * Zip * Phone * Fax * Multiple Practice Locations? * YesNo If yes, please provide additional location addresses and phone numbers. Time Zone * EasternCentralMountainPacificOther What are your office hours? * What year was your practice founded? * 2: DOMAIN INFORMATION AND EMAIL Do you have an existing website? * YesNo If yes, what is the address? (ie: www.yourdomain.com) If yes, would you like the content of your current site transferred to your new Innexus site? Full Content TransferDo Not Transfer Content Do you require a NEW domain name? (ie: www.yourdomain.com) YesNo If yes, do you have any preferences regarding a domain name? (Example: yourcompanyname.com) Do you currently have domain based email setup through your website? * YesNoUnsure 3: WEBSITE DESIGN PREFERENCES Do you have a logo for your practice? * YesNo Practice tagline as it should appear (Or not applicable) * Look and feel of website * Family CarePediatric CareMedical Services Optical ServicesTrendy Fashion Other Additional customer requests 5: BILLING INFORMATION To view pricing information, please open another tab a type getinnexus.com/pricing Billing Contact (Full Name) * Billing Contact Email * Billing Address * City * State * Zip * Add Promotional Code if Applicable Account/Card Type * VisaMasterCardAmerican Express Card Number * Cardholder Name * Expiration Date (MM/YY) * CVV2 (Three digit number on back of Visa/MC, four digit number on front of AMEX) * Innexus Service Agreement How did you hear about Innexus? * Another Eye Care ProfessionalLaboratory RepWeb Vision CentersSearch EngineOnline AdTrade ShowOther If Other: The most current copy of the Innexus service agreement may be found and reviewed by visiting http://www.getinnexus.com/agreement. I understand that billing will begin two weeks after I receive my first proof. Although there are no cancellation fees, the Innexus Website requires a 30-day written notice to Innexus for cancellation and the Innexus + Social Media requires a one-year commitment before cancellation can be requested. Which Innexus program would you like to participate with? * Innexus Website $79Innexus+Social Media $299 I have read and fully agree to the terms and conditions outlined in the Innexus Service Agreement. * Yes Electronic Signature: please provide an electronic signature by typing your name in the box. * NOTE: The form will not submit if all the required fields are not filled in. Upon clicking the submit button, you should see a Thank You Page which indicates your form has been properly submitted. We will then contact you via email within one business day. If you do not see the Thank You Page or have not heard from us within one business day, please call 888-963-8894.