Form

Filling out this form is required to process your data extraction request. Please complete all mandatory fields.

From the date of submission, please note that a minimum of 3 weeks are required to complete this request. If any information is missing, we will have to contact you for assistance, which will result in a longer processing time.

This service is billable to the rate of 500$ (plus applicable taxes) per healthcare professional. A discount may be applicable based on the number of users. Full payment of the resulting invoice is required before migration data is transferred to your new provider.

By completing this form, you confirm that you are authorized to make this request and accept the costs incurred.

First Name*

Last Name*

Email*

Cell phone number

Scope of the extraction*

Please choose the statement that best describes your situation*

Specify the Omnimed institution(s) to extract data from*

Contact info of the person in charge at the destination EMR (name, phone, email)*