Strategic Alliance Partner Form

Thank you for your interest in eClinicalWorks! Please fill out the Strategic Alliance form below and submit it to eClinicalWorks.


Company Details
Company Name:*
Primary Address:*
City:*
State:*
Zip Code:*
Phone:*
Fax:
Email:*
Website Address:

Primary Contact
Name:*
Title:*
Phone:*
Email:*
 

Value of becoming a Strategic Alliance Partner
Please give a brief description of what services your company provides.
*
Why is your company interested in creating a Strategic Partner Alliance
with eClinicalWorks?
*
Who is your target market and customer base?
What territories do you cover?
*
What will this Strategic Alliance relationship bring to eClinicalWorks?
*
 

Do you currently work with an eCW client?
If you have installed, supported or currently support a network and/or provided and installed hardware
for an eClinicalWorks client and you wish to be a client reference, please fill out this section. If not,
please skip to the next

 

Please provide us with 2 customer references of eClinicalWorks clients you have worked with.

(Reference 1)
Practice Name:
Name of Lead Physician:
Office Manager or Other Contact:
Phone:
Email:
When did you begin working with this client?:

  

(Reference 2)
Practice Name:
Name of Lead Physician:
Office Manager or Other Contact:
Phone:
Email:
When did you begin working with this client?:
 

General Company Information
Date Company Established:
Number of Sales Reps:
Total Number of Employees:
Estimated Yearly Revenue:
Your Top 3 Competitors:
Do you work/partner with other EMR/PM Corporations? If so please mention their names:

Product Information

(For products to be integrated with eClinicalWorks solutions)
Product Name:
Current release of your product:
Next scheduled release:
Number of current customers using your product:
Brief overview of product(s):