GENERAL INFORMATION

Please complete the information below for our information. All information received will be kept confidential and will not be released to anyone. Contact will only be for followup only. There is no obligation.

(Required Information)

Practice Name Type of Provider

Last Name First Name (of submitting person)

Address

City State Zip

E-mail address

Individual submitting this form

Area Code Telephone Number

(Optional information)

Fax Info...... Area code Number

Practice/Type of Practice (narrative)

System Presently used

Future Plans (multiple selections allowed)

Indicate number of computer stations now being used or anticipated need

Please indicate other information or comments you feel necessary. (Narrative)

Tricare Medical Resources, Inc.

New_Computer_System
Do_Nothing_Now-Just_considering
Change_Software
Upgrade_Present_Computer(s)
Extend_Present_System