Contact Us
>
Schedule Live Demo and
Request Information
Tell Us About Yourself
*
Fields marked with an asterisk are mandatory.
Your Name (first, last)
*
:
Title:
Company
*
:
Address (mailing)
*
:
Address (additional):
City
*
:
State (or province)
*
:
Country:
Zip (postal) Code
*
:
Email Address
*
:
Phone Number
*
:
Fax Number, if any:
Specialty
*
:
Select One
OD Practice
MD Practice
MD/OD Combined
MD with Optical
Commercial Practice
Non-Doctor Practice
What practice management software are you currently using?
*
What electronic health records software are you currently using?
*
What are your reasons for wanting to change?
What other software are you currently reviewing?
When do you plan to purchase a practice management system?
Less than 1 month
2-3 months
4-6 months
More than 6 months
How many doctors do you have in your practice?
*
How many locations do you have?
*
Based on implementing a practice management and new EMR /EHR system, how many computers would be running maximEyes?
*
How did you hear about maximEyes?
*
Select
Association Meeting
Colleague Referral
Direct Mail Campaign
Email Campaign
Forum or Social Media Site
Magazine/Journal Articles
Ophthalmic Equipment Vendor
Print Ad
Tradeshow
Web Search
Word of Mouth
Other
Do you know anyone currently using maximEyes or has used maximEyes?
If so, please list below.
*
Additional comments:
Type of Request
Mail me a maximEyes SQL informational packet
Call me to schedule an interactive online demonstration
Other (List specific request in "Additional Comments" box above)
CONFIDENTIALITY NOTICE:
First Insight respects your privacy. All information you provide will ONLY be used by First Insight Corporation and its affiliated sales consultants in order to contact you regarding the information you requested. Your personal information will NOT be sold, rented, bartered, or otherwise transferred to other parties.
* Please note, at this time maximEyes SQL is supported only in the U.S.
We cannot honor information requests outside of the U.S.