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Tell us About your Practice
Practice Type	Private Practice Diagnostic Center Small Hospital Large Hospital (100+ beds) University/Academic Institution
Have you Purchased EMR yet?	No Yes
Centricty Type	Centricity 5.5 Centricity 5.6 Centricity EMR 2005 CPS06 Other None
How many active Providers	1-5 6-10 11-20 21-50 > 50
How many active Patients	1-1,000 1,001-5,000 5,001-10,000 10,001-50,000 50,001 - 100,000 100,001 - 500,000 > 500,000
What do you currently use for document management/indexing? *	Looking Docutrak Other
How many documents does your practice process per day?	1-100 101-200 201-500 501-1,000 1,001-2,000 2,001-5,000
Tell us about Yourself
First Name *
Last Name *
Company Name *
Role in Company *	CEO IT Director IT Support VAR Office Manager Back Office Medical Records Physician Other
Address
City
State / Zip	AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Phone Number *
Email *
Confirm Email *
How should we contact you?	Phone Email
When Would you Like to Try InDxLogic?	0-30 Days 2 -6 Months 7 - 12 Months Don't Know
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