First Name * Last Name * Title * Practice Name * Address1 * Address2 City * State * Zip * Phone Area Code & Phone * Email * Practice Management System * EHR System * Practice Specialty * Allergy Cardiology Colon Rectal Surgery Dermatology Endocrinology Family Practice Gastroenterology General Surgery Hand Surgery Hematology Infectious Disease Internal Medicine Neurology Neurosurgery OB-GYN Occupational Med. Oncology Ophthalmology Optometry Orthopaedics Otolaryngology (ENT) Otology Pain Management Pediatrics Physical Therapy Plastic Surgery Podiatry Primary Care Pumonology Spine-Orthopaedic Thoratic Surgery Urology Vascular Surgery Other Number of Physicians * 1 2 to 5 6 to 10 11 to 20 51 to 100 100+ How did you hear about MD Logic? * MD Logic Client Trade Show Consultant Direct Mail E-Mail MGMA Internet Google Other Please check all the apply Sense of Urgency * Immediate 30 Days 30 to 90 Days 6 Montrhs 12 Months No Timetable Comments or Questions *
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