Emed Michigan - AS Form

Custom Websites | IT Support | Appointment Scheduler

Appointment Scheduler Application

To help us understand your office needs please fill out this form

Corporate Info
Practice Name
Owner Name
Phone Number		Fax Number
Address		City
State		Zip

Contact Name		web address
Contact Email

Office Hours
monday
tuesday
wednesday
thursday
friday
saturday
sunday

Services
Type of Service ( New P, Sick Patient, OB annual etc )
Duration of each service
Dates and Times for each service for each Provider
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5
Provider 6
Provider 7


Staff
List all persons who will use the scheduler
Persons will have staff access or manager access
Office staff access
Manager access

Name of Providers
Name of Physicians
Name of Physician Assistants
Name of Nurse Practitioners

List Work hours of each Provider
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5
Provider 6
Provider 7

List Days off for each Provider
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5
Provider 6
Provider 7

Tel: (248) 504-4109 | info@emedmichigan.com