Customer Information Form Printable Version

Customer Information Form

Thank You For Choosing ClientTell, Inc.

Please return this Information Form by fax (229) 242-1562

CONTACT INFORMATION

Practice Name:

Address:

City:

State:

Zip:

Phone:

Fax:

Contact:

Title:

E-Mail:

Back-up Contact:

Title:

E-mail:

Additional E-mail Recipients to receive daily report:

E-Mail:

OFFICE SOFTWARE MANAGEMENT INFORMATION

Medical Mgmt. Software		Version:
Operating System (Windows, etc.)		Contact:
Software Support Provider		Phone:

ADDITIONAL INFORMATION

Days in advance to notify patients(please check one)	1. 2. 3. 4. 5.
Number of physicians in your practice