Office name and Phone number *

Contact Name (Name of the individual Technical Support needs to contact to implement the custom query) *

Report Title (short description of what information is needed) *

How is the data to be selected? (ie: How is this report going to be used?) *

Columns to be included in the report (for example: Patient Name, Date of Birth, Email Address, Phone1, City, Associated Provider) *

Location Always applies

Provider (choose one) * Provider associated with the treatmentProvider associated with the patient’s file

From Date Always applies

To Date Always applies