CLIENT INFORMATION :
Practice Name  
How many Physicians     Email:  
Main Address:  
City  State   Zip
Office Contact (full name):   Phone:  
PMS/EHR/EMR SYSTEM INFORMATION:
Do you have EMR/EHR solution in place:
If Yes: Platform, Vendor Name and EMR vendor Contact Information are required.
Vendor Name:
Contact Info:
Website:
Label  




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