New Account Form

Will your account be medical related?

Yes

Account Set up information

How did you hear about us? *

Company Name *

Number to be answered *

Phone Carrier *

Physical Address

Street *

Time Zone *

City *

State *

Zip *

Billing Address

Billing Address is same as Physical Address?

Billing Street *

Billing City *

Billing State *

Billing Zip *

Main Phone Number *

Email *

Business Hours

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Lunch *

If callers ask for your business hours, is it ok to give it to them, or is there a preference on how we answer that question? *

Protocol Information - This serves as a guide on how to handle calls for your account.

Greeting to be used: *

During business hours: (Explain how you want our Agents to respond to typical calls received by your office. Do you want us to identify as your Answering Service or act as if we are part of your staff? The more information provided the better we are able to meet your needs.) *

After-hours: (If you provide an after-hours service, is there specific criteria to meet before sending someone? Do you have an on-call rotation/calendar to send us, or will someone notify us when it changes?) *

Emergency Situations (if applicable) What defines an emergency for your company? What do we do in the event of an emergency? *

Answering service to take calls *

After office hours
Weekends/Holidays
Anytime your office isn't available
24/7/365

Message box - This is customized to capture the information you need.

Caller's Name

Phone number with area code

Address (include city)

Reason for calling: (We can add a drop- down box for quick choices such as needs immediate service, appointment related, information/pricing request, general message, etc.)

Message Delivery (This can be a combination of any of the options below and can be scheduled for specific times if needed.)

Messages sent by: *

Email
SMS(text)
Fax
Phone
Call in

Deliver messages when taken *

Yes
No
Set times?

Please list set times below *

Please include people to receive messages and any delivery requests in the “Contact Information” section.

Contact Information

Contact #1 Name *

Contact #1 Phone Number *

Contact #1 Email *

Contact #2 Name

Contact #2 Phone Number

Contact #2 Email

Contact #3 Name

Contact #3 Phone Number

Contact #3 Email

Requested Start Date: *

Midwest Answer is hereby authorized to be my answering service and to act as my agent in all matters relating to answering, messaging, and telecommunication services. I agree to the terms and conditions of service, and I agree to pay all charges as per invoice terms. By submitting this form, I acknowledge receipt of ASI Terms and conditions. I understand that my use of any service provided by Midwest Answer constitutes acceptance of these terms and conditions. I authorize Midwest Answer to verify the information given on this application and to receive and exchange credit information concerning this account both now and in the future. Provision of service is contingent upon credit approval. Midwest Answer requires a customer approved protocol in advance of service implementation or services cannot be provided. I understand that Midwest Answer will charge me in advance of usage and that charges in excess of the monthly allowance may be required on a periodic basis. I also understand that Midwest Answer may require changes to this agreement if the plan chosen does not match actual usage of the service. Midwest Answer reserves the right to suspend service at any time in the event of unpaid premiums or changes to the service agreement. Usage will be reviewed quarterly, and rates may be adjusted as indicated.

Would like to receive emails from Midwest Answer

I would like to receive emails from Midwest Answer

Account Set up information

How did you hear about us? *

Company Name *

Number to be answered *

Phone Carrier *

Physical Address

Street *

Time Zone *

City *

State *

Zip *

Billing Address

Billing Address is same as Physical Address?

Billing Street *

Billing City *

Billing State *

Billing Zip *

Main Phone Number *

Email *

Business Hours

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Lunch *

If callers ask for your business hours, is it ok to give it to them, or is there a preference on how we answer that question? *

Protocol Information - This serves as a guide on how to handle calls for your account.

Greeting to be used: *

Explain how you want our Agents to respond to typical calls received by your office. Do you want us to identify as your Answering Service or act as if we are part of your staff? The more information provided the better we are able to meet your needs. *

Do you want our Agents to document all calls with a message? (For example, automated calls, sales calls, callers that state they will call back later, etc.) *

Emergency Situations (if applicable) What defines an emergency for your company? What do we do in the event of an emergency? *

Answering service to take calls *

After office hours
Weekends/Holidays
Anytime your office isn't available
24/7/365

Message box - This is customized to capture the information you need.

Caller's Name

Phone number with area code

New or Current Patient?

Reason for calling: (We can add a drop- down box for quick choices such as appointment related, information/pricing request, general message, etc.)

Message Delivery (This can be a combination of any of the options below and can be scheduled for specific times if needed.)

Messages sent by: *

Email
SMS(text)
Fax
Phone
Call in

Deliver messages when taken *

Yes
No
Set times?

Please list set times below *

Please include people to receive messages and any delivery requests in the “Contact Information” section.

Contact Information

Contact #1 Name *

Contact #1 Phone Number *

Contact #1 Email *

Contact #2 Name

Contact #2 Phone Number

Contact #2 Email

Contact #3 Name

Contact #3 Phone Number

Contact #3 Email

Requested Start Date: *

Would like to receive emails from Midwest Answer

I would like to receive emails from Midwest Answer