dashboard-form Office Signup Prototype CommentsThis field is for validation purposes and should be left unchanged.This section pertains to data stored at the office levelOffice Name*Office Shipping Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Office contact*Office person or manager who we can contact if neededOffice contact phone*Office contact email* Office WebsiteOffice Other InformationAny other Information you would like to add about this practice?Approximately how many practitioners are at this location?* One to Three Four to Six Seven to Ten More than Ten Should we keep this question so that we can get a sense of the size of the practice regardless of how many are participating / interested? Will this be confusing to Sales reps?Section BreakThis Section contains data stored at the Doctor/Practitioner level. Reps can add additional Practitioners as needed. Reps should only add practitioners who are participating (active) Practitioner 1* Dr.PTDOPCPNP PCPMissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Suffix First/Last Required | Prefix/Suffix NOT RequiredPractitioner 1 Email* How many patients does the practitioner see per month?*Of the number of patients per month how many are new?*Practitioner 1 Rebates Very Interested Somewhat Interested Not Interested Don’t Know How Interested is the practitioner in receiving Rebates?Practitioner 1 Other InformationAny other information that you would like to share about this practitionerSection BreakThis Section asks the Rep who is filling out the form to confirm their information Your Name* First Last PULL IN THE NAMES FROM THE REP GROUP
