Client Profile Form

Account Name	Type of Business
Account #	Start Date
Office Address	Suite #
City, State, Zip
Business Phone (Main)	Back Office #
FAX #	Pager #
2nd Office Address	Suite #
City, State, Zip
Business Phone (Main)	Back Office #
FAX #	Pager #
2nd FAX # (If Applicable)	Residence #
Website Address (if any)	E-mail Address
Office Staff
Office Manager
Secretary/Receptionist
Answering Service Contact	Title
Phone	Pager
E-mail
Office Manager	Pager
E-mail
OFFICE HOURS
STAFF HOURS	TIME YOU CONNECT/DISCONNECT FROM ANSWERING SERVICE
Sunday	Sunday
Monday	Monday
Tuesday	Tuesday
Wednesday	Wednesday
Thursday	Thursday
Friday	Friday
Saturday	Saturday
Answer Phrase
Answer Type: Office Recorded Greeting Live Operator Answer
Message Delivery Options (Choose all that apply) all messages non-urgent office messages no messages e-mail messages fax messages
Appointments (check one) Necessary Walk-ins Welcome Call First
Alternate/Associate Name	Pager #
Residence Telephone #	Office Telephone #
Emergency/Urgent Call Procedure
Instructions (check one) Contact Immediately Hold Emergency Calls, I will call in
Facsimile Transmissions
What time of day	How often
CONTACT PREFERENCES
Page every for min.
Page until then try home.
Call home after then page.
If no response received then:	Same procedure for alternate?
Non-Emergency/Routine Calls (check one) Office Will Call For Messages Contact on All Medical Calls
Comments or additional requests