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Contents


Business Information

Date:

Client Name:

Tax ID#:



Business Hours of Operation:



Lunch Period From:



Lunch Period To:



Preferred Payment Method:




Administrative Contact Information

Client Name:

Primary Business Contact (Practice Owner) Primary Business Contact (Practice Owner) Primary Business Contact (Practice Owner)

Office Manager Internal Technical Contact Internal Billing Contact



Staff Member Contact Information

Client Name:

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Email Account Information

Client Name:

Account User First & Last Name or Group Name
Email Address
Password
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Others

Client Name:

Alarm Information:

In order to assist you in case of emergency and to perform technical services after hours when required, we require alarm disarming/arming ability. We have this arrangement with most of our clients.













Trash/Recycling:







Ladder Availability:



Approximate Height:



Location in Office:



Building Access: (for low voltage cabling)

Under Floor Crawl Space Access Location:



Attic Access Door Location:



Staff Members who Need Remote Access to Office Computers:









Practice Management Software Information:

Software Title / Vendor Name:



Account Name:



Administrator Account Username / Password:



Floor Plan:

Please provide a floor plan printed on an 8.5x11 sized sheet of paper identifying the clinical or office function and/or name of each room or area in which computers will be used. If you do not have a floor plan, provide a rough sketch of your office and wall partitions on an 8.5x11 sized sheet of paper. Your floor plan should include the following items. Use a pen to add any details necessary to the floor plan to identify these areas & items:

  1. Clinical rooms function and/or name in which computers will be used (e.g. Exam Room 1)
  2. Administrative rooms function and/or name in which computers will be used (e.g. Front Desk)
  3. Other office rooms function and/or name in which computers will be used (e.g. Consult Office 1, Dr. Brown Private)
  4. Computer location (approximate) in each room/area with a ""
  5. Mark computers that are shared with multiple staff with an "S"
  6. Mark computers that are used by primarily one user or are private with a "P"
  7. Write the first & last names of staff members that use each private computer (marked with a "P") next to the associated computer in your drawing.

A floor plan helps us properly document your network for support and implementation purposes.


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