Strategic Alliance Partner Form

Strategic Alliance Partner Form

Thank you for your interest in eClinicalWorks! Please complete the following and submit it for review. After submission, the eClinicalWorks Product Management and Partner Operations Teams will review your application and reply within 30 days. NOTE: All the fields marked with an asterisk (*) are mandatory.

Contact Information:

First & Last Name *


Phone Number *

Your Email *

Company Details:

Company Name*

Street Address*


State *

Zip Code *

Website Address*

Other Information:

Primary Business:*

Estimated Yearly Revenue*

Who are your top 3 Competitors?*
Competitor 1: Competitor 2: Competitor 3:

Explain why your company is interested in creating a strategic alliance with eClinicalWorks:

Please leave this field empty.