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I Would Like the Following:  A free information package sent to me  A demo with a PhoneTree Patient Messaging Specialist
Your Contact Information (required)
Prefix:	Please Select...                             Mr. Ms. Mrs. Dr.
Name:
Title:
Organization:
Mailing Address:
City, State, Zip:
Primary Email Address:
Office Phone Number:	Ext.
Cell Phone (if preferred):
Best time to reach you:	Please Select...                             Before 9am 9am-12pm 12pm-3pm After 3pm
How did you hear about PhoneTree?	Please Select...                             From another practice From our software vendor At a trade show Ad in Connexion Ad in Physicians Practice Direct mail from PhoneTree Direct mail from someone else MGMA Website
Please Tell Us About Your Practice
Required: What practice management software do you use?	Please Select...                             A4/Healthmatics American Medical ADS MedicsPremier Benchmark MD Benchmark MD Navigator Centricty Centricty Companion - Megawest Compulink DentalMate Dentisoft Dentrix Discus Dolphin DOX EagleSoft eClinicalWorks First Insight Greenway Healthmatics Ntierprise HealthPro XL IMS Interg LiveDDM Lytec Management Plus Mars Medical MaximEyes Medent Medical Manager Medical Mastermind Medics Elite Medinformatix Medisoft MegaWest MicroMD Mims Misys Tiger NetPractice NextGen Oasys Open Dental Ortho2 OrthoChart OrthoEase OrthoTrac PBSI Perfect Care Practice Express PracticeWorks RefractiveWare Sage ScheduleVIEW Softdent Tracker Windent SQL WinOMS CS Other (please specify)
What is your practice's specialty (e.g. pediatrics, oncology)
How many providers total are in your practice?
How many appointments do you have per day?
What types of calls would you like to make to your patients? Check all that apply:	Appointment Reminders Recalls Accounts Payable Reminders Lab Results
Will other departments or clinics be on the system?	Please Select...                             Yes No Not Sure
If so, are all on the same practice management software?	Please Select...                             Yes No Not Sure
If so, are they networked together?	Please Select...                             Yes No Not Sure
How Can We Best Help You?
Please choose the appropriate status of this project for your practice:	Please Select...                             Ready to purchase Planning or budgeting Obtaining competitive information Other (please describe)
What is the primary reason you're seeking automated patient messaging?	Please Select...                             Improve office efficiencies Staff time No-shows Increasing office revenue Other (please specify)

Do you have any questions about any PhoneTree Products, or specific applications relating to you and your organization? We will be happy to provide any information that might be of assistance.