gReminder+™ Upgrade Request Form

Please enter the following information to request the work order needed for your upgrade to gReminder+™

* All fields are required

1) Person Completing This Form

1a. Name: *

1b. Title/Position: *

1c. Phone Number: *

1d. Email: *

2) Practice Information

2a. Practice Name: *

2b. Practice ID Number: *

2c. Names of all authorized MDs currently utilizing gReminder™: * 🛈

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2d. Names of all authorized Mid-Levels currently utilizing gReminder™: * 🛈

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2e. Number of all authorized Rooms currently using gReminder™: *

2f. Are there additional providers that are not utilizing the gReminder™ functionality that would like to start doing so? (additional fees may apply) *

YES

NO

If marked "YES" for 2f., a representative from Modernizing Medicine Gastroenterology will reach out to you.

2g. Would you or any provider be interested in knowing more about gSurvey™? (additional fees apply) *

YES

NO

If marked "YES" for 2g., a representative from Modernizing Medicine Gastroenterology will reach out to you.

3) Person Authorized to Sign the Addendum

3a. Name: *

3b. Title/Position: *

3c. Phone Number: *

3d. Email: *

4) Review and Submit

Please review the information then press “Submit Form” to complete your upgrade request. Thank you.