Practice Management Technologies

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Privacy Guarantee: PMTech guarantees that we will never rent, sell or share your information with any other company.

   Please provide us with the follow information so that we may serve your needs in the most efficient way possible. The more information that you provide us the better we will be able to assess your needs.  A PMTech representative will contact you with 24 hours. Required fields are indicated by *.

  General Information

* Name:  
* Company/Organization:  
* Address 1:  
Address 2:  
* City:  
* State:      * Zip Code:    Country:
* Email:  
* Business Phone:  
Home Phone:  
Cell Phone:  
Fax Number:  
Contact Preference:  
If by phone, contact time?  


Product suite interested in:  
Applications interested in:
(Select all that apply)
    Client Tracking & Billing
  Clinical Record
  Medications Module
  CTB / Accounting Integration
  Claims Management
  Utilization Management and Outcomes
  Billing and Coding Reference Guide
  Web Design
  Billing Service
Do you have SQL Server?  
Interested in a demo of our products?  
Interested in more information?  

  Purchasing Information:

Purchasing timeframe:  
Total number of physicians/users?  
Number of concurrent users?  
Have you budgeted for this purchase?  
Budget for software purchase?  
Agency Annual Budget?  

  Referral Information:

How did you hear about us? Check all that apply
  Direct Mail ( Date of Mailing: )
  Trade Show ( Name & Date of Show: )
  Internet ( Search Engine & Keywords Used: )
  Fax ( Fax Code: )
  Email ( Date of Email: )
  Friend / Colleague ( Name of Person: )
  Other ( Please Specify: )

  Industry Information:

Please provide us with a brief description of what services your agency provides:
Are you issuing or have issued a RFI / RFP recently?  
If so, what release date?  
Do you currently use a Practice Management System?  
If so, who do you use?  
What are the biggest needs that you are looking for in a Practice Management System?


Please provide us with any additional information that you may feel is relevant:


Privacy Guarantee: PMTech guarantees that we will never
rent, sell or share your information with any other company.

Or feel free to contact us at the location below

Practice Management Email Corporate
client tracking and billing software

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