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Join Our AccentHealth Network

There are just a few questions you’ll need to answer to help us pre-qualify you for our complimentary Waiting Room Network TV. Once we get this information you’ll be contacted within two business days.

If you have questions, please contact Patient Education Services at PESLeads@accenthealth.com

Contact Information
Your Name:
Practice Name:
Your Title:
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Business Fax:
Email:
Street Address:
City:
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Office Information
Primary Specialty:	Choose One Allergy Cardiovascular Diseases Endocrinology, Diabetes & Metabolism Family Practice Gastroenterology General Practice Geriatric Medicine Internal Medicine Neurology Obstetrics & Gynecology Otolaryngology (ENT) Pediatrics Psychiatry Pulmonary Disease Rheumatology Urology
	Other:
Practice Type:	Choose One Diagnostic Imaging Center Group or Health System Hospital Waiting Room Lab Medical Group Practice Military Base / Hospital / Clinic Multi Specialty Clinic Other Outpatient Center Pharmacy Private Practice Public Health Clinic Urgent / Ambulatory Care VA Medical Center / Hospital / Clinic
If your practice is part of a large group or health system, what is the name of it?
How many full-time physicians work at this office?
How many part-time physicians work at this office?
How many patients do you see on average in a typical week?
How did you hear about us, (web, referral, fax)?	Choose One Email/Fax Web Office Referral Employee Referral Conference Previously Viewed Program Other

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