AnsweringUSA.com
by Anserphone
 
Physician Information
Name Specialty
Street Home Phone

City

State Zip 2nd line
Beeper Svc Provider
Cell Svc Provider
Do you prefer to receive text messages via your beeper or cell?

Office Information
Street Phone

City

State Zip Back line
Fax  (exchange use only)
Nurse Office Mgr
Hours Dr's Hours

Street Phone

City

State Zip Back line
Fax  (exchange use only)
Nurse Office Mgr
Hours Dr's Hours

Street Phone

City

State Zip Back line
Fax  (exchange use only)
Nurse Office Mgr
Hours Dr's Hours

Please list any partners and/or alternates
Name Office #(s)
Home Exchange
Other

Name Office #(s)
Home Exchange
Other

Name Office #(s)
Home Exchange
Other

Name Office #(s)
Home Exchange
Other

Name Office #(s)
Home Exchange
Other

Emergency Locates (Religious Organizations, Clubs, Friends, Relatives, etc...)

Hospitals

Clinics

Specific / Special Instructions
Please list any specific or special instructions.

(Include any preferences for incoming messages and/or dispatching of calls or messages day, evening, and night. NOTE: Please be specific)


How did you hear about us?
Referred by

Yellow Pages
Advertisement

Internet
Other

Bill To
Name    
Street    

City

State Zip    

Service Activation Date Requested
 

You will be automatically billed every 28 days. You will be responsible for any long distance and extra fees we incur from any outside agencies at your request. We are an after hours emergency service and are staffed based on after hours of operation information given by our clients. We reserve the right to charge for additional services requested and/or provided at your request. In addition, we reserve the right to adjust rates. We will provide written notice prior to price adjustments. In the event of cancellation of services, we MUST receive, in writing, a written notification 30 days prior to cancellation. You will be reminded of the cancellation procedure with each invoice. You will be subject to any fees incurred for collections efforts by an outside agency in addition to your outstanding balance due. It is the client's responsibility to provide up-to-date contact information and account information, as it changes and needs to be updated in our databases. We respect your privacy and do not share any private information with any outside sources.

   

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