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Client Information

Name *Name of the organization.
Contact Person *Name of the authorized person submitting this request.
Organization Address
Address of the organization headquarters. Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone Number *
Email *Email address of the contact person whom the invoices will be sent to.
How many locations will you need our software? *
Service Type *
What primary area of service does your organization focus on?Physical Therapy - AdultOccupational Therapy - AdultSpeech/Language - AdultPhysical Therapy - PediatricOccupational Therapy- PediatricSpeech/Language - PediatricBehavioral Therapy - PediatricOther
If you selected 'other' please describe:
Number of Therapist/discipline (PT, OT, SLP) per Clinical Location *
Please list the number of therapists and their discipline per location.
Number of Assistants/discpline per Clinical Location *
Please list the number of assistants and their discipline per location.
Average TOTAL number of visits *
Number of Planned Future Locations
Number of Therapists per Planned Future Location
Average anticipated Visits per Planned Future Location
Modules / Services *
Check all additional Modules and services that customer wants included. SMS/EMAIL Appointment RemindersCallpointe Reminders (Phone)Patient RegistrationPhysiotecAxiaMed CCReferral ManagementManagement ToolbeltData ImportBilling ServicesFax ServicesABIlity Module (advanced data visualization)
Information *
Please tell us your pain points, and describe any information that will help us understand your organization. The more details you provide, the more accurate the estimate will be.

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