Required information fields are marked with an asterisk (*) and must be completed.    
         
Organization      
Prefix      
First Name      
Last Name      
Address1      
City      
State  
Zip
 
Phone No.      
Email      
I am interested in   EMR (electronic medical records)    
    Billing    
    E- Claims    
    E- Services (ex. E-prescription)    
    Appointment scheduler    
    Software with technical support    
    Software with training    
       
I am interested in purchasing and installing medical billing and records software within    
    the next two weeks    
    the next month    
    the next two months    
    the next year    
         
Single location or Multiple locations? (If multiple how many?)    
       
         
How many doctors do you have?    
       
         
How many computers do you use?    
       
         
What type of billing/scheduling/EMR software do you use currently (If any)?    
       
         
What are the dislikes of your current software?    
       
         
    Submit Clear    
 
 
 
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