Request for Information Business / Company Name: First Name: Last Name: Phone (XXX-XXX-XXXX): Email Address: Practice Management System or Scheduler in use: Where Did You Hear About Us? Please Select We are a Current Customer Referred by Friend or Colleague Scheduling System Provider Direct Mail KLAS Report Google Search Yahoo Search Bing Search Trade Show Trade Magazine Reseller Received a Reminder Call From Us Other *I would like a price quote on: (please select all that apply) RemindMe (Appointment Reminders) Types of Reminders Phone Text / E-Mail / App *Avg. Number of Appointments per WEEK Recall (Periodic Service Reminders) Types of Reminders Phone *Avg. Number of Recall Reminders per WEEK BillReminder (Payment Due Reminders) Types of Reminders Phone *Avg. Number of Payment Due Reminders per WEEK LabPhone (Lab Result Notifications) Types of Reminders Phone *Avg. Number of Lab Result Notifications per WEEK Outreach (Proactive Care Reminders) Types of Reminders Phone *Avg. Number of Lab Result Notifications per WEEK Broadcast (Emergency Closing / Group Calling) Types of Reminders Phone *Estimated Minimum # of Broadcast Calls per MONTH PatientSurveys (Measure Your Performance) Number of Providers Participating in PatientSurveys Comments or Questions: (Are you human?) + =
