Clinware
New Client Intake Form
Organization Name
Main Point of Contact
First Name
Last Name
Phone Number
Email
Company
Company Address
Company Website
Choose a Plan
Select a plan...
Starter for Month by Month
Starter for 1 year with a 10% discount
Professional for 1 year with a 10% discount
Professional for 2 years with a 20% discount
Enterprise for 1 year with a 10% discount
Enterprise for 2 years with a 20% discount
Primary Goals for Using Our Healthcare AI Software (Select all that apply)
Efficiency Improvement
Improved revenue
Accelerate referral process
Reduced Operational Costs
Other (please specify):
Please specify other goals...
Current EHR/Software Integrations (Select all that apply)
PointClickCare
Epic
Matrix
Oracle
Do you have dedicated IT personnel to assist with implementation?
Yes
No
Key Staff Roles Needing Training (Titles/Positions)
Expected Number of Users
Additional Notes or Requests
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