May be used to ship iPads if purchased
Addresses where you would like invoices and W9 forms to be sent, may list more than 1
A number for patients to use if they need to contact the practice
Where should "less than 5-stars" direct patients? Most practices send them to a "feedback" form on their website. Or at minimum a "contact us" form.
Click or drag a file to this area to upload.
This will be used for your registration form and emails
For details about each level, please refer to www.SurgiSurvey.com. We can also set up a phone call to discuss what best suits your practice.
iPads cost $400 each, and will be shipped in a protective case, pre-configured, and ready to start enrolling once connecting to WiFi in your office.

Details about each Doctor

ex: Dr. Orrin Franko
ex: www.ebhmc.com/dr-franko
Where should 5-star reviews be directed? ex: Google or Yelp
Click or drag a file to this area to upload.

Doctor #2 (optional)

ex: Dr. Orrin Franko
ex: www.ebhmc.com/dr-franko
Where should 5-star reviews be directed? ex: Google or Yelp
Click or drag a file to this area to upload.

Doctor #3 (optional)

ex: Dr. Orrin Franko
ex: www.ebhmc.com/dr-franko
Where should 5-star reviews be directed? ex: Google or Yelp
Click or drag a file to this area to upload.