Request Information and Demo CD       Tell Us About Yourself         *Fields marked with an asterisk are mandatory.       Your Name (first, last)*:   Title: Company*: Address (mailing)*: Address (additional): City*: State (or province)*: Country: Zip (postal) Code*: Email Address*: Phone Number*: Fax Number, if any:     Specialty: Optometry Ophthalmology Optical Shop Non-doctor Owned What software are you currently using?* Are you interested in using the software for Electronic Medical Records/Health Records (EMR/EHR) in the exam room? What are your reasons for wanting to change? What other software are you currently reviewing? How did you hear about E-Z Frame?* Select Association Meeting Colleague Referral Direct Mail Campaign Email Campaign Forum or Social Media Site Magazine/Journal Articles Ophthalmic Equipment Vendor Print Ad Tradeshow Web Search Word of Mouth Other Do you know anyone currently using E-Z Frame or has used E-Z Frame? If so, please list below.* When do you plan to purchase E-Z Frame? Less than 1 month 2-3 months 4-6 months More than 6 months   How many optical shops do you have?* How many locations do you have?* Additional comments: Type of Request Mail me a E-Z Frame informational packet and Demo CD Other (List specific request in "Additional Comments" box above)     CONFIDENTIALITY NOTICE: First Insight respects your privacy. All information you provide will ONLY be used by First Insight Corporation and its affiliated sales consultants in order to contact you regarding the information you requested. Your personal information will NOT be sold, rented, bartered, or otherwise transferred to other parties.   * Please note, at this time E-Z Frame is supported only in the U.S. We cannot honor information requests outside of the U.S.