* Required Information

Select a Dinner Informational Session*: Please Select --------------- May 2012 --------------- Tuesday, May 22, 2012: Baltimore, MD Wednesday, May 23, 2012: Washington, DC Wednesday, May 23, 2012: Orlando, FL Thursday, May 24, 2012: Jacksonville, FL Wednesday, May 30, 2012: Houston, TX Thursday, May 31, 2012: Houston, TX --------------- June 2012 --------------- Tuesday, June 19, 2012: Virginia Beach, VA Thursday, June 21, 2012: Richmond, VA Tuesday, June 26, 2012: Chandler, AZ Wednesday, June 27, 2012: Phoenix, AZ Wednesday, June 27, 2012: West Palm Beach, FL Thursday, June 28, 2012: Fort Lauderdale, FL Thursday, June 28, 2012: Pittsburgh, PA

Yes, I will attend: Yes

I would prefer a private meeting: Yes

RSVP code: (Required for fax recipients only)

Last Name*:

First Name*:

MI:

Primary Speciality*:

Secondary Speciality:

Practice Name*:

Total Years in Practice:

Total Years Practicing in the Community:

Are you accepting new patients?: Yes

Numbers of doctors in group: Please Select1-2 3-4 >=5

Are you employed by: Self Group Hospital

Do you currently use an Electronic Medical Record?*: Yes No

Insurance Mix

Medicare:* %

Medicaid:* %

HMO:* %

PPO/POS:* %

POS:* %

HMO Medicare:* %

Cash:* %

Average Number of Patients Seen Per Day*:

Hrs/wk seeing patients in-office*:

Patient Engagement

Hello Health is free to your practice but costs your patients $3 a month to receive the benefits. How likely are you to consider a patient-subscription model if it would bring meaningful value to your patients, patient exceptions can be accommodated and your practice could share in the revenue generated?

Patient subscription model opinion*:Very likely
Somewhat likely
Neutral
Somewhat unlikely
Very unlikely

The Hello Health platform enables secure messaging between your patients and an in-office mail box to streamline communications, reduce phone calls and stimulate visits when clinically appropriate. If secure messaging could improve patient convenience, reduce staff administrative work, improve care collaboration and even offer incremental billing opportunities, would you be open to considering?

Secure messaging opinion*:Very likely
Somewhat likely
Neutral
Somewhat unlikely
Very unlikely

Hello Health is built to give you the option to add web-based consultations to your practice at your discretion. These include secure messaging and video visits. At your option to offer your patients, these visits can provide significant incremental revenue potential to you and enhanced convenience to your patients. Web consults are an integrated capability of Hello Health that you choose if and when to offer your patients. How does this feature impact your interest in Hello Health?

Web-consult interest:*More interested
Neutral
Less interested

Contact Information

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