REGISTRATION PAGE    
All fields must be filled out. (if you don't have or use a feature - just put "none" or answer "no". Thanks)
First Name:
Last Name:
Entity:
Address:
City:
State: 2 Letter
Zip Code:
Country: 3 Letter (ie USA, CAN)
Phone Number:
Fax Number:
Physicians: # FTE's
Nurse Prac/PA's?: # FTE's
Offices: # of sep. offices
Describe Office:
Your office,
populations/location
served, etc.
PR Installed?:
Yes No
PR = Patient Records (PP EMR program)
PR Version: i.e. 9.3.3
PR Licenses: # number of licenses
AS Installed?:
Yes No
AS = Appt. Scheduler
AS Licenses: # number of licenses
Billing Progam?
Yes No
Name of Billing Prog.:
MB Licenses: # of licenses (if applies)
Describe PCs

Describe your range of
PC's and setup - give details
Network Software:
Thin Client?:
Thick Client?:
Yes No
Network More Info:

Describe your network.
Ask your IT person p.r.n.
Database Used:
   
By submitting this form you agree that you are an end-user of Practice Partner products.
Thanks for your time!
Wireless Use?:
Yes No
Wireless Detail:
Faxing Software Use?:
Yes No
Faxing Software Detail:
Voice Recognition Use?:
Yes No
Voice Recog. Detail:
SureScripts/RxHub?:
Yes No
Lab Interface Use?:
Yes No
Lab Interface Detail:
Webview Use?:
Yes No
Webview Detail:

How you use it
with your patients, etc.
Novel Software/Hardware:

Be detailed if you want.
Interesting uses
of technology, etc.
Website Address:
Web Portal: can choose "none"
Web Commerce?:
Yes No virtual visits, pay-bill online, etc.
Other Website Use:

Be detailed if you want.
Email Primary:
Email Alternate:
Username:
  Make sure you use an email that is long term and reliable. Pick a username that others in your clinic can use. A confirmation email with password will come to you in 24-72 hours or so!