Full Name

Email *

Phone *

Practice Name *

Practice Specialty *

How Many Clinics/Providers Does The Practice Have? *

How Many Are Full Time? *

How Many Are Part Time? *

How Many Days Is The Practice Open During The Week? *

What Is Your Monthly Revenue? *

Please indicate monthly revenue per practice if there is more than one practice.

Do You Currently Have Your Own EMR/EHR?

If so, what EMR/EHR are you using?

Are You Currently Billing In-House Or Outsourced?