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Type of Facility/Specialty:  Hospital Multi-Specialty Cardiology Dermatology Emergency Medicine Endocrinology ENT Family Practice Gastroenterology Gynecology Infertility Neurology Ophthalmology Orthopedics Pathology Pediatrics Plastic Surgery Pulmonary Medicine Radiology Rheumatology Urgent Care Urology Other
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Contact Person: 
Name of Facility
Address:            
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Email Address: 
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Are you currently dictating?  Yes No
If yes, what type of recording sytem is being used? 
Are you currently using a transcription service?  Yes No
Projected Volume of dictation in lines or minutes per day:  Minutes Lines
Turnaround time needed? 

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