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Tuesday, September 07, 2010
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Thank you for you Needs Assessment submission. We'll be in touch shortly.
Needs Assessment
What type is your Practice?
Primary Care
Specialty
Primary & Specialty
Hospital
Radiology
Other
What type of solution(s) are you looking for? (Check all that apply.)
Hardware
Software
Biometric Authentication Technology for Healthcare
Electronic Health Record
Personal Health Record
Billing System
Practice Management System
Radiology Information System
Patient Portal
Workflow Process Analysis
Network Solution
Nutrition Application
Website
Managed Services
Other
How many employees are in your company?
1 - 5
6 - 10
11 - 20
21 - 50
51 - 100
100+
How many users will be using the business solution concurrently?
2 - 5
6 - 10
11 - 20
21 - 50
51 - 100
100+
What is your expected time to purchase or implementation?
Right away
Less than a month
1 - 3 months
3 - 6 months
What is your project budget?
$0 - $25,000
$25,001 - $50,000
$50,001 - $100,000
$100,001 - $250,000
$250,000 +
Additional Comments?
Now tell us how to contact you
First Name:
Last Name:
Company:
Job Title:
Address:
Address2:
City:
State/Province:
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code:
Phone:
Fax:
Email Address: