Customer Profile

6688 N. Central Expressway  |  Suite 1140  |  Dallas, TX  75206

Tel 214.821-3850  |  Fax 214.453.3860  |  e-mail: info@SurgicalNotes.com
Facility / Company Name Corporate/Manangement Company (if "Not-In-List" Please add in other...)
Other:
Address City ST ZIP
       
 Person in charge of patient schedules Phone Fax E-mail
       
 Administrator Phone Fax E-mail
       
 Business Office Manager Phone Fax E-mail
       
 Medical Records Manager Phone Fax E-mail
       
 IT Contact Phone Fax E-mail
       
PMS or Scheduling Software (if "Not-In-List" Please add in other...) Target Start Date  (MM/DD/YY)
 Other:   
Accounts Payable Contact Phone Fax E-mail
       
Address City State ZIP
       
Preferred Method of Payment - check one
ACH Transfer - Surgical Notes will provide the required bank routing and account information
Check - Remit to P.O. Box 600043 - Dallas, TX 75360
Credit Card Type: Number: Expiration (YY/MM):
Name on Card:  (Authorization Form may be needed)
Account set-up information checklist - provide all information available - eMail attachments to info@SurgicalNotes.com
List of physicians and credentials eMail info@SurgicalNotes.com OR Upload
Sample reports / standards eMail info@SurgicalNotes.com OR Upload
Facilities names and referring physicians in area
Preferred dictation identification number if available
Special requests / requirements
Desired password for accessing medical records