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Healthcare Application Hosting Quote:
First Name:
Last Name:
Phone Number:
eMail Address:
Company/Organization Name:
Number of Users:
15-50
51-100
101-250
251-500
501+
Number of Servers:
1
2
3-5
6-9
10+
Age of Servers:
0-1 Years
2-3 Years
4+ Years
Healthcare Specific
Are you currently using an EMR?:
Yes
No
No, but planning to
If you are operating an EMR, which application is it?:
Are you looking to host ONLY your EMR, or your full desktop?:
Only EMR
Full Desktop
Any specific comments/questions?:
How did you hear about us?:
Referral from Netgain client
Referral from colleague
Search engine
News Article
Service Provider
Trade show/conference
Other
Corporate Headquarters:
Netgain Technology, Inc.
720 West Saint Germain Street
St. Cloud, MN 56301
877.797.4700
320.251.5030 Fax
info@netgainhosting.com
Sales:
877.797.4700 ext 116
sales@netgainhosting.com
Support:
877.797.4700 ext 2
support@netgainhosting.com
Partner Program:
877.797.4700 ext 116
partnerprogram@netgain
hosting.com