FORM INSTRUCTIONS:  Before entering any data, please gather all required information by clicking each section link below to familiarize yourself with the requirements. When ready to begin, complete the "Business Information" section, double check for accuracy, click "Submit", and proceed to the next form section. Continue this process until all form sections are completed. Note that it's normal for the form to load slowly due to complexity.


 







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//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-1').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});
Business InformationIP: [entry.ClientIP]
Client Name[entry.ClientName]
Date[entry.DateFilled.formatDate(MMM dd, yyyy)]
Site Address[entry.SiteAddress]
City / State[entry.SiteCityState]
TaxID#[entry.TaxID]
BusinessHoursOfOperation[entry.BusinessHoursOfOperation]
LunchPeriodBegins[entry.LunchPeriodBegins]
LunchPeriodTo[entry.LunchPeriodTo]
PreferredPaymentMethod[entry.PreferredPaymentMethod.label]

Date:

Client Name:

Site Address

City / State:

Tax ID#:

Business Hours of Operation:

Lunch Period From:

Lunch Period To:

Preferred Payment Method:



Primary Business Contact1

Primary Business Contact2

Primary Business Contact3

Primary Business Contact4

Primary Business Contact5

Primary Business Contact6

Primary Business Contact7

Primary Business Contact8

Primary Business Contact9


Office Manager

Internal Technical Contact



Internal Billing Contact


AJS.tabs.change(jQuery('a[href="#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-2"]'));
//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-2').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});
Administrative Contact InformationIP: [entry.ClientIP]

First / Last NameTitle / PositionCell Phone #Home Phone #Office Phone # or ExtensionOffice / Personal Email
Owner/Executive #1[entry.FirstLastNamePBC1][entry.TitlePBC1][entry.CellPhonePBC1][entry.HomePhonePBC1][entry.OfficePhoneOrExtensionPBC1][entry.OfficePersonalEmailPBC1]
Owner/Executive #2[entry.FirstLastNamePBC2][entry.TitlePBC2][entry.CellPhonePBC2][entry.HomePhonePBC2][entry.OfficePhoneOrExtensionPBC2][entry.OfficePersonalEmailPBC2]
Owner/Executive #3[entry.FirstLastNamePBC3][entry.TitlePBC3][entry.CellPhonePBC3][entry.HomePhonePBC3][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Owner/Executive #4[entry.FirstLastNamePBC4][entry.TitlePBC4][entry.CellPhonePBC4][entry.HomePhonePBC4][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Owner/Executive #5[entry.FirstLastNamePBC5][entry.TitlePBC5][entry.CellPhonePBC5][entry.HomePhonePBC5][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Owner/Executive #6[entry.FirstLastNamePBC6][entry.TitlePBC6][entry.CellPhonePBC6][entry.HomePhonePBC6][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Owner/Executive #7[entry.FirstLastNamePBC7][entry.TitlePBC7][entry.CellPhonePBC7][entry.HomePhonePBC7][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Owner/Executive #8[entry.FirstLastNamePBC8][entry.TitlePBC8][entry.CellPhonePBC8][entry.HomePhonePBC8][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Owner/Executive #9[entry.FirstLastNamePBC9][entry.TitlePBC9][entry.CellPhonePBC9][entry.HomePhonePBC9][entry.OfficePhoneOrExtensionPBC3][entry.OfficePersonalEmailPBC3]
Office Manager[entry.FirstLastNameOM][entry.TitleOM][entry.CellPhoneOM]
[entry.OfficePhoneOrExtensionOM][entry.OfficePersonalEmailOM]
Internal Technical Contact[entry.FirstLastNameITC][entry.TitleTC][entry.CellPhoneITC]
[entry.OfficePhoneOrExtensionTC][entry.OfficePersonalEmailITC]
Internal Billing Contact[entry.FirstLastNameIBC][entry.TitleBC][entry.CellPhoneIBC]
[entry.OfficePhoneOrExtensionBC][entry.OfficePersonalEmailIBC]
Owner/Executive Owner/Executive Owner/Executive

Owner/Executive Owner/Executive Owner/Executive

Owner/Executive Owner/Executive Owner/Executive

Office Manager Internal Technical Contact Internal Billing Contact



Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact

Staff Member Contact


AJS.tabs.change(jQuery('a[href="#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-3"]'));
//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-3').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});
Staff Member Contact InformationIP: [entry.ClientIP]
#First / Last NameTitle / PositionOffice Phone # or ExtensionOffice / Personal Email
1[entry.FirstLastNameSMC1][entry.TitlePositionSMC1][entry.OfficePhoneOrExtensionSMC1][entry.OfficePersonalEmailSMC1]
2[entry.FirstLastNameSMC2][entry.TitlePositionSMC2][entry.OfficePhoneOrExtensionSMC2][entry.OfficePersonalEmailSMC2]
3[entry.FirstLastNameSMC3][entry.TitlePositionSMC3][entry.OfficePhoneOrExtensionSMC3][entry.OfficePersonalEmailSMC3]
4[entry.FirstLastNameSMC4][entry.TitlePositionSMC4][entry.OfficePhoneOrExtensionSMC4][entry.OfficePersonalEmailSMC4]
5[entry.FirstLastNameSMC5][entry.TitlePositionSMC5][entry.OfficePhoneOrExtensionSMC5][entry.OfficePersonalEmailSMC5]
6[entry.FirstLastNameSMC6][entry.TitlePositionSMC6][entry.OfficePhoneOrExtensionSMC6][entry.OfficePersonalEmailSMC6]
7[entry.FirstLastNameSMC7][entry.TitlePositionSMC7][entry.OfficePhoneOrExtensionSMC7][entry.OfficePersonalEmailSMC7]
8[entry.FirstLastNameSMC8][entry.TitlePositionSMC8][entry.OfficePhoneOrExtensionSMC8][entry.OfficePersonalEmailSMC8]
9[entry.FirstLastNameSMC9][entry.TitlePositionSMC9][entry.OfficePhoneOrExtensionSMC9][entry.OfficePersonalEmailSMC9]
10[entry.FirstLastNameSMC10][entry.TitlePositionSMC10][entry.OfficePhoneOrExtensionSMC10][entry.OfficePersonalEmailSMC10]
11[entry.FirstLastNameSMC11][entry.TitlePositionSMC11][entry.OfficePhoneOrExtensionSMC11][entry.OfficePersonalEmailSMC11]
12[entry.FirstLastNameSMC12][entry.TitlePositionSMC12][entry.OfficePhoneOrExtensionSMC12][entry.OfficePersonalEmailSMC12]
13[entry.FirstLastNameSMC13][entry.TitlePositionSMC13][entry.OfficePhoneOrExtensionSMC13][entry.OfficePersonalEmailSMC13]
14[entry.FirstLastNameSMC14][entry.TitlePositionSMC14][entry.OfficePhoneOrExtensionSMC14][entry.OfficePersonalEmailSMC14]
15[entry.FirstLastNameSMC15][entry.TitlePositionSMC15][entry.OfficePhoneOrExtensionSMC15][entry.OfficePersonalEmailSMC15]
16[entry.FirstLastNameSMC16][entry.TitlePositionSMC16][entry.OfficePhoneOrExtensionSMC16][entry.OfficePersonalEmailSMC16]
17[entry.FirstLastNameSMC17][entry.TitlePositionSMC17][entry.OfficePhoneOrExtensionSMC17][entry.OfficePersonalEmailSMC17]
18[entry.FirstLastNameSMC18][entry.TitlePositionSMC18][entry.OfficePhoneOrExtensionSMC18][entry.OfficePersonalEmailSMC18]
19[entry.FirstLastNameSMC19][entry.TitlePositionSMC19][entry.OfficePhoneOrExtensionSMC19][entry.OfficePersonalEmailSMC19]
20[entry.FirstLastNameSMC20][entry.TitlePositionSMC20][entry.OfficePhoneOrExtensionSMC20][entry.OfficePersonalEmailSMC20]
21[entry.FirstLastNameSMC21][entry.TitlePositionSMC21][entry.OfficePhoneOrExtensionSMC21][entry.OfficePersonalEmailSMC21]
22[entry.FirstLastNameSMC22][entry.TitlePositionSMC22][entry.OfficePhoneOrExtensionSMC22][entry.OfficePersonalEmailSMC22]
23[entry.FirstLastNameSMC23][entry.TitlePositionSMC23][entry.OfficePhoneOrExtensionSMC23][entry.OfficePersonalEmailSMC23]
24[entry.FirstLastNameSMC24][entry.TitlePositionSMC24][entry.OfficePhoneOrExtensionSMC24][entry.OfficePersonalEmailSMC24]
25[entry.FirstLastNameSMC25][entry.TitlePositionSMC25][entry.OfficePhoneOrExtensionSMC25][entry.OfficePersonalEmailSMC25]

Please see the attached Floor Plan document below

Alternatively, you may attach a Microsoft Excel spreadsheet containing data points below by clicking the "Browse" button on the bottom of this form.

1
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

Please click the "Choose Files" button below, select your spreadsheet document, and click "Submit".



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//$('#aui-pane-uid-504237dd-055e-4b76-8afd-bf9aa94b2202-4').find('#i_ClientName_ClientName').val("[entry.ClientName]").change();

$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});
Email Account InformationIP: [entry.ClientIP]
#Account User First / Last Name or Group NameEmail AddressPassword
1[entry.FirstLastNameACUser1][entry.EmailACUser1][entry.Password1]
2[entry.FirstLastNameACUser2][entry.EmailACUser2][entry.Password2]
3[entry.FirstLastNameACUser3][entry.EmailACUser3][entry.Password3]
4[entry.FirstLastNameACUser4][entry.EmailACUser4][entry.Password4]
5[entry.FirstLastNameACUser5][entry.EmailACUser5][entry.Password5]
6[entry.FirstLastNameACUser6][entry.EmailACUser6][entry.Password6]
7[entry.FirstLastNameACUser7][entry.EmailACUser7][entry.Password7]
8[entry.FirstLastNameACUser8][entry.EmailACUser8][entry.Password8]
9[entry.FirstLastNameACUser9][entry.EmailACUser9][entry.Password9]

We will need access to all current 3rd party web-based email accounts (gmail, yahoo, etc) used internally by staff in order to migrate them to the new email system. Note that this form does not need to be completed if all company email addresses reflect your website domain (e.g. John@FamilyMedical.com).

Account User First & Last Name or Group Name
Email Address
Password
1

2

3

4

5

6

7

8

9













Alarm Info:

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 all of our clients.



Trash/Recycling:



Ladder Availability:



Building Access: (for low voltage cabling)

Staff Members who Need Remote Access to Office Computers:

Practice Management Software Information:















$('.cf_action_message *').hide();
//AJS.messages.info('.cf_action_message',{title: '',body: '<p>Thank You!</p><p>We have received your submission.</p>'});
$("#custom-overlay").css('position','fixed');
$("#custom-overlay").css('top','0');
$("#custom-overlay").css('left','0');
$("#custom-overlay").css('right','0');
$("#custom-overlay").css('bottom','0');
$("#custom-overlay").css('z-index','2');
$("#custom-overlay").css('cursor','pointer');
$("#custom-overlay").show();
$("#custom-success-message").addClass("cf_action_message");
$("#custom-success-message").css('top','40%');
$("#custom-success-message").css('right','30%');
AJS.messages.success('#custom-success-message',{title: 'Thank You!',body: '<p>We have received your submission.</p>'});

$("#custom-overlay").click(function () {
    $("#custom-overlay").fadeOut("slow");
});
$(document).on('aui-message-close', function (e) {
    $("#custom-overlay").fadeOut("slow");
});
Alarm InformationIP: [entry.ClientIP]
Alarm Vendor Name[entry.AlarmVendorName]
Alarm Vendor Account Number[entry.AlarmVendorAccountNumber]
Alarm Disarming Procedure[entry.AlarmDisarmingProcedure]
Alarm Arming Procedure[entry.AlarmArmingProcedure]
Alarm Building Entrance / Exit Path[entry.AlarmBuildingEntranceExitPath]
Alarm Building Location[entry.AlarmBuildingLocation]
Alarm Company Support Hotline[entry.AlarmCompanySupportHotline]
Alarm Disarm Call In Verification Password[entry.AlarmDisarmCallInVerificationPassword]
Trash/Recycling
Outdoor trash/recycling container location[entry.TrashRecyclingContainerLocation]
Are trash/recycling containers ever locked?[entry.TrashRecyclineEverLocked.label]
Trash/recycling container lock key location[entry.TrashRecyclineContainerLockKeyLocation]
Ladder Availability
Ladder Available?[entry.LadderAvailable.label]
Approximate Height[entry.LadderApproximateHeight]
Location in Office[entry.LadderLocationInOffice]
Building Access: (for low voltage cabling)
Under Floor Crawl Space Access Location[entry.UnderFloorCrawlspaceAccess]
Attic Access Door Location[entry.AtticAccess]
Staff Members who Need Remote Access to Office Computers
First / Last Name[entry.FirstLastName01]
First / Last Name[entry.FirstLastName02]
First / Last Name[entry.FirstLastName03]
First / Last Name[entry.FirstLastName04]
First / Last Name[entry.FirstLastName05]
First / Last Name[entry.FirstLastName06]
First / Last Name[entry.FirstLastName07]
First / Last Name[entry.FirstLastName08]
First / Last Name[entry.FirstLastName09]
First / Last Name[entry.FirstLastName10]
Practice Management Software Information
Software Title / Vendor Name[entry.SoftwareTitleVendorName]
Account Number[entry.AccountNumber]
AdministratorAccountUsername/ Password[entry.AccountPassword]