*First Name:

*Last Name:

*Organization:

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*Select the department that best describes your role within your organization:
Please Select HIM (Medical Records) PFS / Business Office / Finance Ancillary (Lab, Radiology, Emergency Room) Quality, Compliance, Risk, Infection Control I.T. / I.S. Transcription Executive / C-suite Case / Utilization Management Physician Office / Clinic Scheduling / Admissions / Registrations Other

*Select the title that best matches your own:
Please Select Executive / C-suite Department Manager / Director Manager / Supervisor End user Other

*Do you have the authority to purchase this product or service?
Please Select Yes No

*How can we help you to engage the appropriate decision-makers within your organization?
Please Select Have a sales representative call Provide a personal demonstration Provide pricing information Send literature, fact sheets, webinar info

*How were you informed about this product or service?
Please Select Webinar Mail or E-mail literature Tradeshow / Convention Referral from another facility/hospital Website / Internet Don't know Another vendor / Consultant Other

*Why are you interested in this/these products or services?
Please Select Have an identified problem Evaluating solution(s) Information gathering Education

*What is your timeframe for making a final purchasing decision for this/these products or services?
Please Select 0 - 12 months 1 - 2 years 2 + years Not decided