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Shelton, CT 06484
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Information Request Form

*First Name:
*Last Name:
*Practice Name:
*Street Address:
Address (cont.):
*Zip/Postal Code:
*Work Phone:
Please help us select the version of the software appropriate for you:
Current Billing System:
Years Used For:
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 (All disciplines)
The Paperless Office For Chiropractic®
The Paperless Office For PT®
In addition, I am interested in:
Patient Notes  Medical Billing  Voice Dictation Scanning
Please send a Trial Copy, Literature and Demo Materials
Please Send References Information
Please arrange a consultation to discuss my requirements
Please prepare a proposal
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Please arrange to install the trial on my system with my data
        (requires about one hour and a high speed connection)

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