Zoho Forms

New Client Questionnaire

To help us better your serve your facilities needs. Please provide us with the following information below.

Name *
First Last
Title *
Phone *
Email *
Facility Name *
Corporation Name *
Total Licensed Beds:
Occupancy % rate:
Readmission rate:
Current EMR:

Electronic Medical Record Provider
Have you ever tried telemedicine at your facility, currently or in the past?
Are you interested in utilizing telemedicine to track patient vitals?
Facility Type
Check all that apply to your needs.
I want to reduce my readmission rate I seek to increase my census I need instant, reliable nocturnal coverage I aspire to a higher 5 star rating I desire more word-of-mouth advertising I would love to be the hospital's preferred SNF for referrals I consider cost savings and a high ROI to be important

New Client Questionnaire