Agency Registration — PulseIQ EMS Management

Agency Information

Tell us about your EMS agency so we can tailor your account setup.

Agency Name * ⚠ Agency name is required.

Agency Type * ⚠ Please select an agency type.

Street Address * ⚠ Street address is required.

City * ⚠ City is required.

State * ⚠ State is required.

ZIP Code * ⚠ ZIP code is required.

Main Phone Number * ⚠ Phone number is required.

Website (optional) ⚠ Enter a valid URL (starting with https://).

Primary Contact

Provide the person authorized to coordinate evaluation, contracting, and secure administrator activation.

First Name * ⚠ First name is required.

Last Name * ⚠ Last name is required.

Email Address * ⚠ A valid email address is required.

Phone Number * ⚠ Phone number is required.

PulseIQ will never ask you to create or send a password in an application form. If your agency is approved, the administrator will receive a secure, single-use activation link.

Operations

Provide some basic operational details about your agency.

Number of Personnel * ⚠ Enter at least 1 personnel.

Number of Stations * ⚠ Enter at least 1 station.

Number of Ambulances * ⚠ Enter at least 1 ambulance.

I confirm that I am authorized to request an evaluation for this agency. I understand this is an application only and does not create an account, accept a contract, or activate service.

⚠ You must confirm your authority to submit this application.

The Terms of Service, Privacy Notice, and Subprocessor Disclosure are effective as of August 28, 2026. Submitting this evaluation application does not accept a contract or activate service. Do not include patient information or PHI.

Review & Confirm

Please review your information below before submitting your pilot application.

Pilot Application

Agency Information

Primary Contact

Operations

Review & Confirm