Client Application – FxMedSupport

Let's Get Some Information

Basic Information
Company Name
Website
Business Fax
Business Phone*
Address
Do not need to add if it is same as your Website

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Owner
First Last
Business Owner Phone
Business Owner Email
Office Main Contact
First Last
Office Main Contact Phone
Office Main Contact Email
Practice Information - Basic
Type of Medical Practice
- Brick & Mortar
- Virtual
- Hybrid
Services provided
Services Location Scheduling (How Online,Phone, Walk-in) # of Provider/Chairs/Rooms/Ect
Number of licensed providers
Number of providers that can prescribe
Team
Name Email Position Cost
EMR
Add all that apply
Name Provider Portal Patient Portal
Practice Information - Lab
Labs
Company Name Account Number Contact Name & Number
Practice Information - Supplement
Supplement
Company Name Account Number Contact Name & Number
Practice Information - Applications
**ALL** Applications,Systems,Programs used
Examples: Phone, Fax, Video, Texting, Bulk Email (List Service), Website Chat, Webhost, Music, Storage Service, *The more you provide the more we can leverage
Name Website Function Cost
Needs, Wants, Desires
Information on your needs, wants and desires?
What is the scope of the desired project?

Save and Continue Later

Services	Location	Scheduling (How Online,Phone, Walk-in)	# of Provider/Chairs/Rooms/Ect

Name	Email	Position	Cost

Name	Provider Portal	Patient Portal

Company Name	Account Number	Contact Name & Number