Part I. User Information.

1.  Dr. Mr. Ms. Mrs. Miss *First Name  MI *Last 

2. *Contact Phone Number 

3. *E-Mail Address 

4.  Fax Number


Part II. Practice Information.

1. *Practice Name 

2. *Practice Address 

  *City     *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Armed Forces     *Zip 

3. *Specialty Area AIDS/HIV Allergy Anaesthesiology Cardiology Chiropractics Clinical Pharmacology Dental Dermatology Emergency medicine Endocrinology Gastroenterology Genetics Gynaecology/Obstetrics Haematology Hepatic and Biliary Disorders Immunology Infectious diseases Intensive care Nephrology Neurology Nutrition Oncology Other Otorhinolaryngology Paediatrics Psychiatry Pulmonology Radiology Rheumatology Surgery Urology

4. Number of Physicians in Practice: Under 4  5-8  9-12  15 or more

5. Number of Staff: Under 15  5-15  16-25  26 or more

6. Name of Office Manager    *First  *Last 

7. *Phone 


Part III. Current Practice Management Software Information and Functions.

1. Current Practice Management Software: Medical Manager  Millbrook  Healtheon
   If other, please specify

2. Current Version

3. Are you Satisfied? Yes  No  Unsure

4. Are you interested in an Internet-Based System Yes  No  Unsure


Part IV. Main Functions of Existing Software.

1. Office Management: Yes  No  Unsure

2. Clinical: Yes  No  Unsure

3. Prescriptions: Yes  No  Unsure

4. Electronic Data Interchange: Yes  No  Unsure

5. Estimated Number of Claims: Under 200  300-500  600-800  Over 1000

6. Estimated Number of Patients: Under 200  300-500  600-800  Over 1000

7. Features You Would Add
  

8. Features You Would Want Improved
  

9. Features You Would Eliminate
  

10. Set-up an Email Account with DrOffice Technologies Inc.?  Yes  No