QUICK QUOTE
Please enter requested information:
Practice Name:
Address 1:
Address 2:
City: State: Zip:
Office Phone:
Office Fax:
Office Contact:
Email:
Best Time to Call You:
New to after-hours triage? Yes
Using another triage service? Yes
Name of current service provider:
Night Nurse is pleased to offer a comparison of fees and services.
Additional comments:
I am interested in obtaining a Quote for Services: Yes
I would like to initiate services effective:
Practice's average monthly after-hours call volume:
Number of Physicians in Practice: Full Time Part Time
Night Nurse Coverage Hours Desired:
MONDAY - from
p.m. to
a.m.
TUESDAY - from
p.m. to
a.m.
WEDNESDAY - from
p.m. to
a.m.
THURSDAY - from
p.m. to
a.m.
FRIDAY - from
p.m. to
a.m.
SATURDAY - from
p.m. to
a.m.
SUNDAY - from
p.m. to
a.m.
Night Nurse will contact you upon receipt of your request with a quote for services Response may be expected within 48 hours.
Please send a service agreement for review Yes
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