Omalas Technology

Transcription Client Questionnaire

Please provide us with the following information so that we can offer you a customized quote for your transcription services.

* are required fields

Contact Name *

Company Name or Name of Healthcare Entity

Address *

City *

State *

Zip/Postal Code *

Phone Number *

Fax Number

Email Address *

Service Request *

Urgency *

How is your care currently being documented?

Handwritten (Optional)

Inhouse Transcriptionists (Optional)

If using a service, what is your average volume? (Optional)

Billing Period (Optional)

Current Method of Dictation: (Optional)

How many providers will be utilizing the service? (Optional)

What is your required turn-around time? (In hours e.g. 12/24/36 etc)(Optional)

Do you have multiple locations/satellites? *

What is your desired start date? (mm/dd/yy) (Optional)

Comments (Optional)