Please provide the following contact information: (* = Required)

*Business Name:
 

*Last Name:   *First Name:
 

*Mailing Address:

 

* City:
 

* State/Province: Select State/Province ALABAMA ALASKA ALBERTA AMERICAN SAMOA ARIZONA ARKANSAS BRITISH COLUMBIA CALIFORNIA CANAL ZONE COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LABRADOR LOUISIANA MAINE MANITOBA MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW BRUNSWICK NEW FOUNDLAND NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHWEST TERRITORIE NOVA SCOTIA OHIO OKLAHOMA ONTARIO OREGON PENNSYLVANIA PRINCE EDWARD ISLAND PUERTO RICO QUEBEC RHODE ISLAND SASKATCHEWAN SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING YUKON
 

* Zip/Postal Code:
 

* Telephone:
 

Fax:
 

* Email:
 

Please complete the following to help us serve you better:
 

How did you learn about Accurate? ---- Select One ---- Advertisement Postal mail from Accurate E-mail from Accurate Online web search Referral Physician directory Accurate called me Other
 

Can we thank someone for referring you?
 

What type of facility are you contacting us from? ---- Select One ---- Single Physician Office Multiple Physician Office Surgery Center Clinic Hospital Other
 

What is your specialty?
-- Hold Ctrl To Select Multiple Areas -- Acupuncture Allergy/Immunology Andrology Anesthesiology Audiology Bariatrics Cardiology Chiropractic Clinical Chemistry Clinical Virology Dentistry Dermatology Emergency Medicine Endocrinology ENT Environmental Medicine Epidemiology Family Medicine Forensic Medicine Gastroenterology Genetics Geriatrics Hematology/Oncology IME/Peer Reviews Infectious Disease Internal Medicine Neonatology Nephrology Neurology Nuclear Medicine Obstetrics and Gynecology Occupational Medicine Occupational Therapy Ophthalmology Optometry Oromaxillofacial Orthopedics Osteopathy Otolaryngology Pathology Pediatrics Plastic Surgery Podiatry Preventive Medicine Psychiatry Psychology Pulmonology Radiation Oncology Radiology Reproductive Medicine Rheumatology Social Work Speech Therapy Sports Medicine Surgery Urology Vascular Medicine Other
 

What type of reports do your doctors dictate?
-- Hold Ctrl To Select Multiple Areas -- H&P Consultations Operative Reports Discharge Summaries Progress/Clinic Notes SOAP Notes Correspondence ER Radiology Reports Pathology Reports Outpatient Surgery IME/Peer Reviews EEG Reports EMG Reports EKG Reports PSG Reports Cardiac Catheterizations Other

How many of your providers would use our service?
 

How many dictations do you do per day?
 

How do you currently handle your transcription?
-- Hold Ctrl To Select Multiple Areas -- In-House Outsourced to U.S. based transcription company Outsourced to overseas transcription company Outsourced to independent transcriptionist Other
 

Have you outsourced your transcription before? ---- Select One ---- Yes No
 

What percentage of your volume is outsourced?
 

What are your outsourcing objectives?
-- Hold Ctrl To Select Multiple Areas -- Improve quality Improve turnaround time Improve technology Overflow/backup support Lower costs Just shopping Other
 

What is your turnaround requirement?
---- Select One ---- 2 Hours 12 Hours 24 Hours 48 Hours 72 Hours Other
 

How do your doctors prefer to dictate?
-- Hold Ctrl To Select Multiple Areas -- Phone Digital recorder Microphone / computer PDA Tape Our Lanier system Our Dictaphone system Our DVI system Our WinScribe system Other
 

How do you prefer to receive your reports back?
-- Hold Ctrl To Select Multiple Areas -- Email Remote printing Fax Electronic signature FTP Courier / mail Other
 

What word processor do you use? ---- Select One ---- MS Word WordPerfect Other
 

What type of Internet connection do you have? ---- Select One ---- Dial-up High-speed
 

How soon are you looking to make a transition? ---- Select One ---- Currently 2-3 Months 6 Months Just Looking
 

Other Comments: