Rollins Healthcare Data Systems

Would you like us to send you this Demo on CD-ROM?

Yes No

Name:

E-mail Address:

Practice Name:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone Number:

Fax Number:

Are you currently using an in-house computer system?

Yes No

If Yes, which system are you currently using?

What is your primary Operating System (OS) ?

Windows 9x
Windows 2000
Windows XP Home
Windows XP Pro

Unix
Linux
Mac
Other

How Many Physicians are there in your practice?

What is your practice Specialty?

When do you plan to purchase or upgrade your system?

Is there any additional information which may be helpful for us to know?