(
*
Indicates required field)
Email Address :
*
First Name :
*
Last Name :
*
Title :
*
Hospital / Clinic Name :
Address (or P.O. Box) :
Address (Slot#/Room# ) :
City :
State :
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip :
Daytime Phone # :
*
Ext:
Other Phone # :
Ext:
How did you hear about CoagClinic?
Select How you heard about CoagClinic
Current CoagClinic Customer
Meter representative
Pharmaceutical rep
USI
Other
Number of patients you are managing or planning on managing :
Select Number
< 100
100 - 500
> 500
> 1000
Software you are currently using to track your warfarin patients (if any):
Point of Care meter you are using or plan on using (if any):
Select Point of Care meter
CoaguChek S-Roche
INRatio-HemoSense
ProTime-ITC
I-Stat
Other
None
Which best describes your clinic?
Starting a clinic
Have an existing clinic