Customer Information

Please fill out the applicable spaces below.




*Practice Name/Business Name:
*Address:
*City:
*Country:
*State:
*Zip:
 Different Billing Adress
Address:
City:
Country:
State:
Zip:
*Office Phone 1:
Office Phone 2 :
Private/Unlisted Office:
Area Code:

Fax:
*Email:
Web Site Address:
Specialty (if applicable):


Contact Name :


Cell:
Cell Phone Carrier:
Home Telephone:
Beeper:
Call Home After:
Please Contact Me By


Contact Name :

Cell:
Cell Phone Carrier:
Home Telephone:
Beeper:
Call Home After:
Please Contact Me By

Contact Name :

Cell:
Cell Phone Carrier:
Home Telephone:
Beeper:
Call Home After:
Please Contact Me By


Interest in using Anserve's online access?

Office Manager:


 Yes No

Staff Hours:
Call Relay Instructions:
Fax or Email Messages:
Time(s) Of Days(s) To be Sent:
Coverage Changes at:
Coverage Dr. Name:
Hospital Affiliation:
Reason For Leaving Last Service:

Client Login Request a Quote

Testimonials

Lifeline Medical Associates

It is my pleasure to write this on behalf of Robert Ward. We have been customers of Anserve, Inc. for five years. Throughout this time, we have had the pleasure of always receiving the best of service. This service covers our messages, pagers and our monthly billing. They are always on the cutting edge of communication technology.

Ginny Doyle (Practice Manager)


Read more