Welcome to the Healthcare Connections Program Application
We appreciate your interest in becoming an Authorized Dragon Medical Partner. We recommend that you print and review the application prior to entering information into this form. This application has been designed to incorporate your 1st year business plan in order to streamline the application and approval process. Please note that completion of this application does not guarantee approval into this program. If you have any questions please email HealthcareChannel@Nuance.com.

Thank you for your application for the Healthcare Connections Channel Partner Program.

Download a PDF of the enrollment application

Click here to edit your existing enrollment

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Username / Password
*Email ID as Username
*Password (min 6 characters)
*Confirm Password
Applicant Information
*Company Name
*Company Website
*Phone
*Address	200 Character Limit
*City
*State	-Select One- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Northwest Territories Nunavut
*Country	-Select One- Canada USA
*Zip/Postal Code
*Tax ID
Number of Additional Sites
*Primary Medical Specialty	-Select One- Allergy and Immunology Anesthesiology Cardiology Chiropractic Dentistry Dermatology Ear Nose Throat Emergency Medicine Family Medicine Internal Medicine Neurology Neurosurgery Nuclear Medicine Obstetrics and Gynecology Onocology Ophthalmology Orthopedic Surgery Other Pathology Pediatrics Physical Medicine and Rehabilitation Plastic Surgery Psychiatry - Mental Health Psychology Radiation Therapy Radiology Surgery General Surgery Specialties Urology
Partner Program Manager *
*First Name
*Last Name
*Phone
*Email Address
*Opt in to receive Connections Partner Program emails Yes   No
CEO / Owner	Same as above
*First Name
*Last Name
*Phone
*Email Address
*Opt in to receive Connections Partner Program emails Yes   No
VP of Sales	Same as above
*First Name
*Last Name
*Phone
*Email Address
*Opt in to receive Connections Partner Program emails Yes   No
Primary Technical Contact
*First Name
*Last Name
*Phone
*Email Address
*Opt in to receive Connections Partner Program emails Yes   No
Pre-Sales Technical Certification Candidate	Same as above
Authorization to resell Dragon Medical requires a minimum of 1 Dragon Medical Technical Certification. Please name your candidate here.
*First Name
*Last Name
*Phone
*Email Address
*Opt in to receive Connections Partner Program emails Yes   No
Sales Certification Candidate
Authorization to resell Dragon Medical requires a minimum of 1 Dragon Medical Sales Certificate. Please name your candidate here.
*First Name
*Last Name
*Phone
*Email Address
*Opt in to receive Connections Partner Program emails Yes   No