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Physician Profile Form

Use this form to set up new accounts and to make changes to existing accounts


General Office Information
Account Name
Office Specialty
Account Number
Date you would like service to start?
Office Address
Suite Number
City
State
Zip Code
Office Main Number
Back Line Number(for Excel use only)
Fax Number
 
Second Office Address
Suite Number
City

State
Zip Code
Second Office Main Number
Back Line Number(for Excel use only)
Fax Number
 
Website Address (if any)
E-mail Address
Answer Type
(Check One)
Live Operator
Answer Phrase For Operator
Recorded Message
What Message Do You Want On The Recording?
Office Hours
Staff Hours
Doctors Hours

Sunday

Sunday
Monday Monday
Tuesday Tuesday
Wednesday Wednesday
Thursday Thursday
Friday
Friday
Saturday Saturday
Appointments
(Check One)


Emergency / Urgent Call Procedure
(Check One)

Hold all calls and fax or e-mail on next business day
  What time of day do you want messages sent to you at?
  The fax or e-mail to be used
Contact immediately
Please check the appropriate calls you would like to be contacted for:
Other doctors Any hospital department calls
Admissions / Transfers Nursing homes or Hospice
Notice of patient's expiration Normal lab results
Critical lab results Consultations
Signature for death certificate (funeral home / coroner)
Patient returning doctor's call Patient is out of town and needs a prescription
Patient questions Surgery / Procedure cancellation
High fever
Pain
Patient calls a second time
Patient calling for lab results Problems with medication
Patient has never seen doctor, but has an appointment and needs to speak to you
Caller just states it is urgent to speak to doctor
Other
Would you like calls from pharmacy when office is closed?
New prescription calls
Comments, additional request and special instructions
Office Staff

1st Physicians Name

Medical Specialty

Pager Number
Home Number Cell Phone Number
Emergency Contact Preferences Are:
Page every minutes  for  minutes
Page until   A.M or P.M. then try home
Call home after   A.M or P.M. then page
If no response received then:
2nd. Physicians Name Medical Specialty
Pager Number
Home Number Cell Phone Number
Emergency Contact Preferences Are:
Page every minutes  for  minutes
Page until   A.M or P.M. then try home
Call home after   A.M or P.M. then page
If no response received then:
3rd. Physicians Name Medical Specialty
Pager Number
Home Number Cell Phone Number
Emergency Contact Preferences Are:
Page every minutes  for  minutes
Page until   A.M or P.M. then try home
Call home after   A.M or P.M. then page
If no response received then:
4th. Physicians Name Medical Specialty
Pager Number
Home Number Cell Phone Number
Emergency Contact Preferences Are:
Page every minutes  for  minutes
Page until   A.M or P.M. then try home
Call home after   A.M or P.M. then page
If no response received then:
Answering Service Main Contact:
Person's Name Title
Office Number
Other Contact Number
Office Manger's Name  
Secretary / Receptionist Name(s)
Any Other Office Staff Name and Title
Any Other Office Staff Name and Title
Any Other Office Staff Name and Title
Non-Emergency / Routine Calls
(Check One)
Office will call for messages  Contact on all calls
Fax messages at A.M or P.M. to this fax number  
E-mail messages at A.M or P.M. to this e-mail address

Comments, additional requests and special instructions

Please List The Hospitals You Are Associated With

Hospital Name

Telephone Number

Hospital Name

Telephone Number

Hospital Name

Telephone Number

Hospital Name

Telephone Number