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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