Integration Request
Contact Information
Let us know who you are and the most effective way to reach you!
Name
*
First Name
Last Name
Title
Title
Preferred Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Convergent Representative Name
First Name
Last Name
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Practice Information
Practice Name
*
Please provide the name of the practice requesting our services.
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
From your practice, who will be the main point of contact for this project?
*
I will be the main point of contact.
Someone else will the main point of contact.
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Project Point of Contact
Please provide us the contact information of the project's main point of contact.
Name
*
First Name
Last Name
Title
Title
Preferred Phone Number
Please enter a valid phone number.
Email
*
example@example.com
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Software Information
Please provide us information regarding your EMR or LIS vendor.
Company Name
*
Software Name
Software Type
Please Select
Electronic Medical Record (or similar)
Laboratory Information System (or similar)
Practice Management System (or similar)
Has the third party vendor been engaged?
*
Yes. I have a vendor representative's contact information.
No. This information will provided at a later date.
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Vendor Contact Information
Representative Name
First Name
Last Name
Representative Title
Title
Representative Phone Number
Please enter a valid phone number.
Representative Email
example@example.com
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Integration Information
My practice will be...
Sending electronic orders to Convergent
Receiving electronic results from Convergent
Other
Integration Direction
Bidirectional
Unidirectional
Please provide any additional information you would like us to know.
Specifications and sample messages help us evaluate the scope of work associated with your project. Please provide any specifications or sample messages here. PLEASE OMIT ANY PHI (Protected Health Information) FROM SAMPLE MESSAGES.
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