Thank you for your interest in Practice Fusion. Please tell us a little bit about yourself so we can schedule you for a product demonstration where you will be able to view the Practice Fusion solution up-close and hear insight into the daily use of an EMR.

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First name:
Last name:
Title:
Company/Practice Name:
City:
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Telephone:
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You are a:	RHIO Administrator MCO/MSO/IPA Practitioner Practice Manager Billing Service Insurance Provider Other
Your specialty:	Various Not Applicable Allergy and Immunology Cardiology Cardiovascular Surgery Endocrinology Family Practice Gastroenterology General Surgery Geriatrics Gynecology Hematology Infectious Disease Internal Medicine Nephrology Neurology Neurosurgery Obstetrics and Gynecology Oncology Ophthalmology Otology and Otolaryngology Pediatrics Physical Medicine/Rehabilitation Plastic Surgery Podiatry Preventive Medicine Psychiatry Pulmonary Disease Radiation Oncology Thoracic Surgery Urology Vascular Surgery Other Not applicable
Number of Practitioners in your org:
Plan to integrate solution in:	0-3 months 4-6 months 7-12 months More than 12 months Not applicable
How did you hear about us:	Advertisement Direct Mail/eMail DOQ-IT Newspaper/Trade Article Partner Press Release Trade Show Web Seminar Word of mouth Other