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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.

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I am interested in obtaining a Quote for Services:    Yes

I would like to initiate services effective: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2010 2011

Practice's monthly after-hours call volume: estimate less than 20 20-99 100-199 200-299 300-399 400-499 500 and up

Number of Physicians in Practice:   Full Time    Part Time

Night Nurse Coverage Hours Desired:

   MONDAY -from --- 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to-  --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

   TUESDAY -from --- 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to- --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

   WEDNESDAY -from --- 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to- --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

   THURSDAY -from --- 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to- --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

   FRIDAY -from  --- 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to- --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

   SATURDAY -from --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to- --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

   SUNDAY -from --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00 11:00 p.m.  -to- --- 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 a.m.

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