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Organization / Company Name
Contact Person Name
Phone
Fax
Email
Type of Facility
Hospital Single
Physician Practice
Group
No. of Locations
No. of Health Care Professionals who would be using our service
Specialty
Average Number of reports/week
Mode of Dictation
Select Dictation Mode
Phone
Handheld Recorder
Other - Please Specify
If other
Turnaround Time
Select Turnaround Time
Next day (12-24 hours)
Same day: Please specify hours
24-48 hours
48-72 hours
Hours
What amount of work would you likeTradecom to bid upon
Select Amount to bid
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
Overflow only
Occasional Work
After Hours/Weekend Coverage
How soon do you need the service
Select Time Line
Immediately
Within 1 Month
Within 2-4 Months
Within 2 weeks
4-6 Months
How did you hear about us
Select From Source
Search Engine
Link from another web site
Convention/Conference
Referral from a friend/colleague
Postcard or Mailer
Other
If other
Additional Comments