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First name
Last name
Email
Phone
Name of Practice
Specialty
Number of providers
Phone
Email
Practice management system / EHR vendor
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First Name
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Last Name
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Email
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Phone Number
🇺🇸
🇦🇫 Afghanistan (افغانستان) +93
🇺🇸 [placeholder for all other country codes]
🇿🇼 Zimbabwe +263
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Practice or Organization Name
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Specialty
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Dermatology
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City
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State
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Current PMS
ModMed Practice Management
EZClaim (EZDerm)
eClinicalWorks PM
DrChrono Practice Management
AdvancedMD Practice Management
Nextech Practice Management
Other
MedicsPremier (Advanced Data Systems)
athenaCollector (athenahealth)
CareCloud Central
CGM Medisoft
CollaborateMD
Greenway Intergy PM
NextGen Practice Management
Office Ally Practice Mate
OpenPM (Open Practice)
PracticeSuite
Tebra Practice Management
Oracle Cerner Practice Management
Not Sure
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Number of Full-Time Providers
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I'm starting a new practice
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What is your role?
Physician-Owner
Owner / Partner
Practice Manager
Practice Administrator
Clinician
C-Level Executive (e.g., CEO, CFO)
Office Manager
Billing Manager
Other
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How did you hear about us?
Google
Facebook Group
Word of Mouth
Direct Mail
eMail
Other
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Anything else we should know?
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