Information Request


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Information Request

Please fill in the information below, then click the Submit button to send it to CSC. We will ship you a complete information package which includes a brochure, a full demonstration CD and a full working copy of the software. A CSC representative will contact you to answer questions, provide a proposal or assist with the trial installation.

Required information is marked with an asterisk (*)

Information Request Form

*First Name:
*Last Name:
*Title:
*Practice Name:
*Street Address:
Address (cont.):
*City:
*State/Province:
*Zip/Postal Code:
*Country:
*Work Phone:
Fax:
*E-mail:

*Specialty:
Current Billing System:
Years Used:

Current Operating System:
*Number of workstations:
*Number of Providers:

I plan to purchase in about: months.

*Product Information Request*
Patient Appointments Scheduler The Physicians Paperless Office® - MD version The Paperless Office For Chiropractic® The Paperless Office For PT® E-Z Template Builder For AS/PC®

*In addition to Medical Records, I am interested in:*
Patient Notes Medical Billing Voice Dictation Please send literature and a Self Running Demo package Please have your dealer call me to set up a demonstration Self-running demo CD Live demonstration Trial Package With Scanner ($399.00 - Non-refundable) Please have a representative call

Comments:

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