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) Necessary Walk-ins Welcomed Call First

Emergency / Urgent Call Procedure (Check One) Hold emergency calls, I will call in 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 Orders 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? Yes No New prescription calls Refill request Questions from pharmacist 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

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