Place Your Order - Viewpoint Screening

1

Required Package
The Physical Therapy program at Trine University requires the following services to be performed.
Health Portal:	At the end of the order process, you will have the capability to log in and upload specific documents required by your school for immunization, medical or certification records.
Price:	$25.00

I have read, understand and agree to the Viewpoint Screening Disclaimer.

Applicant Information
Do not place an order on someone's behalf. This form must be filled out by the individual who requires Viewpoint Screening services.
First Name^*:
Last Name^*:
Middle Name:
Alias/Maiden Name 1:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 2:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Alias/Maiden Name 3:	Please Note: If you DO NOT have an alias name, leave this field blank. Only provide if you have used an alias within the last 7 years.
Date of Birth^*:	/ / (mm/dd/yyyy)
Student ID^*:
Gender^*:	Male Female
E-Mail Address*:	IMPORTANT Your email address will be your user name to log in. Login names cannot be changed. Please make sure you are entering your correct email address. You will be unable to log in or receive communications from Viewpoint Screening if your email address is not valid. Please make sure you are entering your correct email address. You will be unable to log in or receive communications from Viewpoint Screening if your email address is not valid. Type E-mail address. Re-type E-mail address. If you already have an account: Please use the same email address associated with your current account to prevent separate logins. Separate logins will contain separate results / medical documents, and cannot be combined.

Current Residential Address:
Address^*:
City^*:
State or U.S. Territory^*:	For an international address, select "International" and select the foreign Country name below.
Country^*:
Zip Code^*:	ZIP Code Look Up Tool Please Note: If you have an international address that does not require a Zip Code, please fill in "00000".

Payment Information

First Name^*:
Last Name^*:
Credit Card Number^*:
Exp. Date^*:	(MM/20YY)
CVV^* ?
Credit Card Type^*:
Contact Name (if business):
Email^*:	Payment receipt will be sent to this email
Phone Number^*:
Address^*:
City^*:
State^*:
Postal Code^*:
IMPORTANT: Please note that if you enter an address other than the one on file with the credit card's issuing bank, or an incorrect CVV code, Viewpoint Screening will deny your transaction for security purposes. Additionally, denied transactions may cause the funds to be held by your bank for up to 5 business days before being released back to the card. A Parent or Guardian's credit card will be accepted. The cardholder should be made aware of this transaction. Cancelled payments will result in account removal and/or additional fees. "Viewpoint LLC" will appear on your credit card statement. A W-9 form will not be provided to third party organizations. ATTENTION: Your credit card will be charged $ 25.00 when you click "Next." This price is for the package that you selected. If you did not select the correct package, do not continue. Go back and select the correct package. You have agreed to the Terms of Use and Refund Policy and you understand that this fee is non-refundable under any circumstances. Any payment disputes will result in account removal and/or additional fees. Do not click more than once or you may be charged multiple times.

Payment in process. Please wait. Do not close this page until you receive confirmation.

web design and hosting by BlueTone Media