Help Us Understand Your Needs

Discovery Intake Form

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Please Tell Us About Yourself

Name

Job Title

Organization Name

Email

Phone

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Your Organization's Business Type(s)

(Check all that apply.)
Practice
Teleradiology Practice
Imaging Center
Hospital Department
Other
(Please tell us more.)

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Modalities Covered

(Check all that apply.)
CT
MRI
X-Ray
PET
Ultrasound
Other
(Please tell us more.)

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Capacity

(Numbers only please.)

Annual Volume

Annual Revenue

Number of Locations

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Operational Needs

Your Business Objectives
(Please summarize a few key examples.)

Your Primary Pain Points
(Please summarize a few key examples.)

Use Cases
(Please summarize a few key examples.)

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Technology Systems

PACS (Please tell us the system name, if known.)


RIS (Please tell us the system name, if known.)


Call Center (Please tell us the system name, if known.)


EMR (Please tell us the system name, if known.)


Ordering System (Please tell us the system name, if known.)


Staffing System (Please tell us the system name, if known.)


Business Intelligence System (Please tell us the system name, if known.)


Billing/Finance/Claims System (Please tell us the system name, if known.)


HL7 Feed (If known, please tell us the number of feeds, data contained, etc.)


DICOM Feed (Please tell us the version, if known.)


Other Feeds
(Please tell us more.)

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Staff Counts

(Numbers only please.)

Radiologists

Schedulers

Technologists

IT

Total Staff

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Additional Information

(Please share anything else that we should be aware of.)

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