Application Form

Name

Clinic Name

Address Line 1

Address Line 2

Province

Postal Code

Phone

Email

Implementation Timeframe

EMR Status

Practice Details

NameMSP Billing

Physician

+ Add Physician

- Remove Physician

Please select your type of application:

ITSP

Pre-Purchase

Please indicate what you intend to purchase through the Pre-Purchase Program (Select all that apply):

Hardware (PCs, printers, scanners - not servers)

EMR Software

Early Adopter

Please indicate what you intend to purchase through the Pre-Purchase Program (Select all that apply):

Moving to a new clinic without historical records

Need to purchase new hardware to replace existing or prepare for initiatives such as CDM

Please indicate what you intend to purchase through the Pre-Purchase Program (Select all that apply):

Hardware (PCs, printers, scanners - not severs)

EMR Software