Temp Form for Approval

First Name *

Last Name *

Email *

Direct Contact Phone Number *

Role *

Physician

Nurse Practitioner

Registered Nurse

SIPPA

Resident

Clerk

Fellow

Other

Name of Preceptor/Attending

First Onsite Date of Rotation

City

Hospital/Clinic/Site Name

Department/Specialty

Types of Reports you will be dictating *

Inpatient

Outpatient

History & Physical

Discharge

Operative/Procedure

Consult

Other

Other *

EMR/Application you will be dictating into *

Sunrise Clinical Manager (SCM)

Med Access

QHR Accuro

Momentum Healthware (Mental Health Addiction Services)

Microsoft Word

Other

Other *

Additional Comments

Dictation - Self-Edit Software Request