InHealth Request Form

*Name:

*Practice Name:

*Address:

*City:

*State:

Country:

*Zip Code:

*Telephone:

*Email:

Where did you hear about us?:

I Would Like:

Additional Comments:

(chars left: 1000)

Please complete as much information in the fields below. This will allow us to demonstrate specifically where our product will save you time. It will also allow us to immediately provide you with a proposal.

Group speciality(s):

Total number of providers:

Breakdown of providers per location:

(chars left: 1000)

Average number of patients seen per day across all locations:

Average number of NEW patients seen per day across all locations:

Total number of pages in a typical chart:

Average number of faxes sent and received per day across all locations:

Preferred diagnostic laboratories (i.e. LabCorp, Quest):

Network operating system:

Number of workstations: