BUSINESS INFO ONLY, PLEASE EMAIL TO: , FAX TO: 1-800-877-6392, OR CLICK 'SUBMIT' AT THE END OF THIS PAGE.

Facility Name *

and Type *

Primary Contact Name & Title *

Facility Address, Ste, City/ State/Zip

Facility Tel *

Facility Fax

Primary Contact Tel

Primary Contact Fax

Primary Email

Secondary Email

Building Mngmt Contact Name

and Tel

• PLEASE FAX (1-800-877-6392) or EMAIL , with your NAME in the subject line, THE ROSTER LIST OF ALL HEALTHCARE PROVIDERS AT FACILITY WITH:

• PROVIDER FIRST AND LAST NAME, ADDRESS, PHONE, FAX, EMAIL, SPECIALTY, AFFILIATIONS, ME #

Please check all that apply:

• Do you have Internet access in your office?        Yes       No

• If Yes, is it… DSL     Cable     Satellite     Dial-Out    Other

• Is there a power outlet in your waiting room?      Yes       No

• Is there room for a 3x3 foot stand in the waiting room?  Yes       No

• Is there an active phone line in your waiting room?    Yes       No

• Who is your local phone carrier?

• How many physicians currently practice in your office? 

• How long have you had your current computers in your office?

• How many computers are in your offices?

• Do you currently have a network of linked computers in your office?    Yes       No

• Do you use a practice management software program?   Yes     No   

• If Yes, Name

• Do you anticipate moving locations within the next 6 months?  Yes       No

How did you hear about us?   Referral    Mail     Fax     Email    Meeting     Ad     Publication

Other

Would you like to provide us with a referral so we can send them information?       Yes       No

If  Yes, please provide  Facility Name and Type

Contact Name, Tel, Fax, Email