Practice Name *

Practice Specialty *

Primary Contact Name *

Contact Title *

Contact Email *

Contact Phone *

Address *

Street Address

City

State

Postal Code

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 Current Monthly Revenue? *

What is your average monthly patient volume? *

Do You Currently Have Your Own EMR/EHR? *

If so, what EMR/EHR are you using?

Are You Currently Billing In-House Or Outsourced? *

If outsourced billing, what company are you currently using?

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