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Name of Practice
Contact First Name
Contact Last Name
Phone Number
Fax Number
Email
Address
City
Province/State
Postal Code
How many clinic locations do you have?
Which modalities do you perform?  X-Ray
 Ultrasound
 BMD
 Mammography
 Fluoroscopy
 Nuclear Medicine
 MRI
 CT
Other  
Approximate # of Exams per year
Current Information System
What is your expected timeframe for implementing a new RIS?  N/A
 6 month or sooner
 6 - 12 months
 1 - 2 years
Which PACS system do you have or are considering?
What is your expected timeframe for implementing a PACS?  N/A
 6 month or sooner
 6 - 12 months
 1 - 2 years
Other Information

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