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Company Name:
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Address:
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Please list the products that
you currently represent:
Are any of these products an EHR program?
If so, please list the EHR programs.
 Yes No
Have you offered EHR programs in the past?
List products.
 Yes No
Are you currently a VAR for another company?
If so, which company/companies?
 Yes No
How long have you been in the
medical records field?
 Years
How long have you been in the
medical accounting field?
 Years
How many employees do you
have in your company?
 Total
Sales
Technical
Administration
How many current clients do you have?

Total
Podiatry
Ophthalmology/Optometry
Dermatology
OB-GYN
Orthopedics
Rheumatology
Neurology
Family/General Practice
What are your anticpated sales of Charting Plus for the first year? (Existing Clients)
What are your anticpated sales of Charting Plus for the first year? (New Clients)
What is the typical practice size of
your existing client base?
 (# physicians)
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