HEALTHeWV: A New Vision for Rural Health Care

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Clinic Request Form

* - indicates required information

First Name*
Last Name*
Title
Company*
Street Address*
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Work Phone*	- -
FAX	- -
E-mail*

Does your clinic schedule appointments with an electronic system? If so, what system do you use?
Does your clinic bill electronically? If so, what system do you use?
Request HeWV Program Brochure
Request a Demo
Request a representative to call you
Number of Providers in your clinic*
Number of exam rooms
Internet connectivity in exam rooms	Yes No
Comments:


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