EMR/EHR Survey

Practice Name

How many Physicians

How many locations/sites

Main Address:

City

State

Zip

Office Phone Number:

Office Contact (full name):

Technical Personnel Contact (if available):

Do you have EMR/EHR solution in place:

Yes
No

If Yes: Platform, Vendor Name and EMR vendor Contact Information are required.

Platform (if available):

Web-based
Client-server based

Vendor Name:

Contact Info (if available):

Website (if available):

Tel:

Email:

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Bako Pathology Services