Wufoo

Name * First Last
Name of practice *
Number of nephrologists in your practice *
City of practice
State of practice
Email *
Phone Number * ### - ### - ####
Preferred method of contact
Email Phone
Do you currently have admitting privileges at a DaVita dialysis center?
Yes No
Please indicate the Falcon product(s) you are interested in. Check all that apply. *
Falcon ESRD in DaVita dialysis centers Falcon EMR Falcon Lab and DVA Laboratory Services Falcon Access and Lifeline Vascular Access
Do you currently round at a DaVita dialysis center?
Yes No
Are you currently using an EMR?
Yes No
If you are currently using an EMR, what EMR do you use?
If you are currently using an EMR, where are you using it?
At my practice At the hospital
How satisfied are you with your current EMR?
Extremely satisfied Satisfied Neutral Unsatisfied Extremely unsatisfied
Are you looking to switch EMRs?
Definitely Maybe Undecided Definitely not
What lab are you currently using?
Does the above lab interface with your EMR?
Yes No
Where do you currently send patients for their access procedures?
What practice management system are you currently using?
Are you responsible for IT decisions for the practice?
Yes No
How did you hear about us?
Do Not Fill This Out

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