Thank you for your interest in Avid's OneLook Anesthesia Billing and Practice Management Software. For further information on our products and services, please complete the form below.         
          
          Fields marked * are required.   (To return to the previous page, hit the back button on your browser.)  

Contact Name*:                                                  E-Mail*:
  
Practice Name*:                            Our Business is:                       Current Billing Performed by:
    ---- Please select one ---- Anesthesia/Pain Group Anesthesia Billing Service Pain Management Only Multi-Specialty Billing Service Consultant Other     ---- Please select one ---- In-House Staff Third Party Billing Service Other
 Address*:                                       Current Billing Software:         Current Billing Service:
         
City*:                                ST*:         Zip*:
       
Phone*:                               Fax:
        

 
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  of this form.  If you would just like information,  press the Submit button at the end of this form now.

# of
Physicians                                                                  Number of Billing Staff/Workstations:
CRNAs  Employed byGroup Hospital       Average Anesthesia Case Volume:      / day month year
Residents                                                                    Average Pain Case Volume:                 / day month year
Legal Entities/Groups we bill for                            Pain Cases are Primarily: Please select one Acute Chronic

EDI Requirements:   I Prefer --Please select one -- Direct Interfaces Clearinghouse       Medicare Medicaid Blue Commercial 

 My Interests are:                 
OneLook Billing and Practice Management Software OnePay Program    
HIPAA Off-Site Backup Ad-Hoc Crystal Reports    Document Imaging       
Electronic Statements Demographic Downloads Collection Interface

Other Information about your business you would like us to know:

Installation timeframe:                What Search Engine did you use:               What Search Terms did you use:
days month(s)                ---- Please select one ---- Google MSN Yahoo Ask Jeeves Copernic Other....................................