Step One -- Tell us about your medical practice/organization:

Practice/Organization Name (Required):
<% if session("regcustomer") <> "" then %> <% else %> <% end if %>
Address 1 (Required):
<% if session("regaddr1") <> "" then %> <% else %> <% end if %>
Address 2:
<% if session("regaddr2") <> "" then %> <% else %> <% end if %>
City (Required):
If outside of USA, please include Province/Country.
<% if session("regcity") <> "" then %> <% else %> <% end if %>
ST (Required):
--Select One-- selected<% end if %>>AK selected<% end if %>>AL selected<% end if %>>AR selected<% end if %>>AZ selected<% end if %>>CA selected<% end if %>>CO selected<% end if %>>CT selected<% end if %>>DC selected<% end if %>>DE selected<% end if %>>FL selected<% end if %>>GA selected<% end if %>>HI selected<% end if %>>IA selected<% end if %>>ID selected<% end if %>>IL selected<% end if %>>IN selected<% end if %>>KS selected<% end if %>>KY selected<% end if %>>LA selected<% end if %>>MA selected<% end if %>>MD selected<% end if %>>ME selected<% end if %>>MI selected<% end if %>>MN selected<% end if %>>MO selected<% end if %>>MS selected<% end if %>>MT selected<% end if %>>NC selected<% end if %>>ND selected<% end if %>>NE selected<% end if %>>NH selected<% end if %>>NJ selected<% end if %>>NM selected<% end if %>>NV selected<% end if %>>NY selected<% end if %>>OH selected<% end if %>>OK selected<% end if %>>OR selected<% end if %>>PA selected<% end if %>>RI selected<% end if %>>SC selected<% end if %>>SD selected<% end if %>>TN selected<% end if %>>TX selected<% end if %>>UT selected<% end if %>>VA selected<% end if %>>VT selected<% end if %>>WA selected<% end if %>>WI selected<% end if %>>WV selected<% end if %>>WY selected<% end if %>>Outside of USA
Zip (Required):
<% if session("regzip") <> "" then %> <% else %> <% end if %>
Time Zone:
--Select One-- selected<% end if %>>Pacific selected<% end if %>>Mountain selected<% end if %>>Central selected<% end if %>>Eastern
Phone number (Required):
<% if session("regphone") <> "" then %> <% else %> <% end if %>
Facsimile number:
<% if session("regfax") <> "" then %> <% else %> <% end if %>
E-Mail Address:
<% if session("regemail") <> "" then %> <% else %> <% end if %>
Primary Specialty:
--Select One-- selected<% end if %>>Anesthesiology selected<% end if %>>Cardiology selected<% end if %>>Diagnostic Radiology selected<% end if %>>Family Practice selected<% end if %>>Gastroenterology selected<% end if %>>General Practice selected<% end if %>>General Surgery selected<% end if %>>Gynocology selected<% end if %>>Hematology selected<% end if %>>Hematology/Oncology selected<% end if %>>Infectious Diseases selected<% end if %>>Internal Medicine selected<% end if %>>Multi-Specialty Clinic selected<% end if %>>Nephrology selected<% end if %>>Neurology selected<% end if %>>OB/GYN selected<% end if %>>Obstetrician selected<% end if %>>Oncology selected<% end if %>>Orthopaedics selected<% end if %>>Pediatrics selected<% end if %>>Physical Therapy selected<% end if %>>Plastic/Reconstructive Surgery selected<% end if %>>Podiatry selected<% end if %>>Radiology selected<% end if %>>Radiation Oncology selected<% end if %>>Respiratory selected<% end if %>>Rheumatology selected<% end if %>>Urology selected<% end if %>>Other
<% if session("regnolocations") <> "" then %>Number of Office Locations: <% else %>Number of Office Locations: <% end if %>
<% if session("regnoproviders") <> "" then %>Number of Providers in Your Practice: <% else %>Number of Providers in Your Practice: <% end if %>

Step Two -- Tell us about yourself:

Contact Name (Required):
<% if session("regcontactname") <> "" then %> <% else %> <% end if %>
Title:
<% if session("regcontacttitle") <> "" then %> <% else %> <% end if %>

Medigrate.com includes a private Customers Only site which includes product downloads and upgrades, and an authentication code request form. With time, other useful information for our Electronic Office customers will be added. The site is limited to only those customers with valid Usernames and Passwords on file. You can register your Username and Password now, or contact us at 1.877.Medigrate with your username and password once you become a registered customer. Access to the Customers Only site is provided through the login button at the top of the Electronic Office home page.

Username (4-15 characters):
<% if session("regusername") <> "" then %> <% else %> <% end if %>
Password (4-10 characters):
<% if session("regpassword1") <> "" then %> <% else %> <% end if %>
Confirm Password:
<% if session("regpassword2") <> "" then %> <% else %> <% end if %>

Step Three -- Tell us about your computer system(s):

Workstation operating system:
(If mixed, then select the most common)
--Select One-- selected<% end if %>>Windows 95/98 selected<% end if %>>Windows NT selected<% end if %>>Windows 2000
Network server operating system (if applicable):
--Select One-- selected<% end if %>>Not Networked selected<% end if %>>Citrix selected<% end if %>>Novell selected<% end if %>>Windows 95/98 selected<% end if %>>Windows NT selected<% end if %>>Windows 2000
Number of computers
on your network (if applicable): <% if session("regnosystems") <> "" then %> <% else %> <% end if %>

Step Four -- Tell us about your copy of Electronic Office:

Serial Number (Required):
Must be entered EXACTLY as it appears
in any Electronic Office About Box, including
UPPER-CASE and lower-case letters, and hyphens
<% if session("regserialno") <> "" then %> <% else %> <% end if %>
Version
(Required):
<% if session("regversion") <> "" then %> <% else %> <% end if %>
How do you wish to receive your
Monthly Authentication Codes (Required)?
--Select One-- selected<% end if %>>Mail selected<% end if %>>Fax selected<% end if %>>E-Mail
Pricing Option (Required)?
--Select One-- selected<% end if %>>Pricing Option One selected<% end if %>>Pricing Option Two
How did you obtain your copy of Electronic Office?
--Select One-- selected<% end if %>>Called Medigrate selected<% end if %>>Downloaded from Website selected<% end if %>>Received in Mail selected<% end if %>>Requested on Website selected<% end if %>>Sales Call from Medigrate selected<% end if %>>Trade Show/Conference selected<% end if %>>Other

Step Five -- Tell us anything else you think we should know:

checked<%end if%>>Place a check here to receive e-mail notices about future updates and releases.

Miscellaneous Comments, Questions, or Suggestions:
<% if session("regcomments") <> "" then %><%response.write session("regcomments")%> <% else %><%response.write request.querystring("comments")%> <% end if %>