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Enroll in ECCO

Please fill out the information below to become a member of the ECCO program. As an ECCO member you will be notified of upcoming ECCO campaigns that match the interests of you and your patients. Through campaign participation you will become eligible for ECCO rewards and member benefit programs. If you prefer to speak to an ECCO representative, please call 800.670.4526 or email info@eccodocs.com.

Contact & Office Location Information

Name of Doctor:

  

Office Manager:

  

Address:

  

Apt/Suite:

City:

  

State:

-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY   

Zip Code:

   

Phone:

   

Fax:

Email:

   

 I have another office location(s). Please call/email for more details.

How many additional offices?   

Preferred contact method:  

 Phone

 Email

Programs Interested in

I am interested in:  

 Health Panels

 Interactive Television Program

Interested in TV's — are you currently using any in the office? 

Yes   No

 Complimentary Medical Products (as available/per campaign)

 Clinical Trials

 Join the Devon Health PPO Network

 All of the above

Patient Statistics

Type of Practice:

-- Acupuncture Addiction Counseling Adolescent Medicine Adolescent Weight Management Allergy / Immunology Anatomic Pathology Anesthesiology Audiology Audiometry Bariatrics Biofeedback Bone Marrow Transplant Breast Surgery Burn Treatment Cardiology Cardiothoracic Surgery Cardiovascular Diseases Child & Adolescent Therapy Child Psychiatry Child Psychology Chiropractic Clinical Pathology Clinical Pharmacology Clinical Psychology Colorectal Surgery Counseling Couples Counseling Critical Care Dentistry Dermatology Dermatopathology Dietician Dispensing Optician Ear, Nose, Throat Electrodiagnostic Medicine Electrophysiology Emergency Medicine Endocrinology Endodontics Family Counseling Family Planning Family Practice Gastroenterology General Practice General Surgery Genetics Geriatric Counseling Geriatrics Gynecologic Oncology Gynecology Hand Surgery Hand Therapy Head & Neck Surgery Hematology Hematology / Oncology Hematology/Oncology Hepatology Hyperbaric Medicine Hypertension Infectious Diseases Internal Medicine Marriage Counseling Massage Therapy Maternal Fetal Medicine Maxillofacial Surgery Medical Genetics Mental Health Counseling Metabolic Diseases Midwifery Neonatology Nephrology Neurological Surgery Neurology Neuropathology Neurophysiology Neuropsychiatry Neuropsychology Neuroradiology Neurosurgery Nuclear Medicine Nurse Practitioner Nursing Nutrition Obstetrics / Gynecology Occupational Medicine Occupational Therapy Oncologic Surgery Oncology Ophthalmic Dispenser Ophthalmology Ophthalmology ( Cornea ) Ophthalmology ( Glaucoma ) Ophthalmology ( Laser Surgery Ophthalmology ( Neuro ) Ophthalmology ( Plastics ) Ophthalmology ( Retina ) Optometry Oral Pathology Oral Surgery Orthodontics Orthopedic Surgery Orthopedics Orthotics / Prosthetics Osteopathic Manipulation Other Otolaryngology Pain Management Part-time Preceptor Pathology Ped. Allergy / Immunology Ped. Anesthesiology Ped. Cardiology Ped. Cardiothoracic Surgery Ped. Counseling Ped. Critical Care Ped. Dentistry Ped. Dermatology Ped. Dev. & Behavior Ped. Diag. Referral Ped. Disabilities Ped. Ear, Nose, Throat Ped. Emergency Medicine Ped. Endocrinology Ped. Gastroenterology Ped. General Surgery Ped. Genetics Ped. Hematology / Oncology Ped. Infectious Diseases Ped. Neonatology Ped. Nephrology Ped. Neurology Ped. Neuropsychology Ped. Neurosurgery Ped. Nutrition Ped. Oncology Ped. Ophthalmology Ped. Orthopedic Surgery Ped. Orthopedics Ped. Pathology Ped. Perinatology Ped. Physical Medicine Ped. Plastic Surgery Ped. Psychiatry Ped. Psychology Ped. Pulmonology Ped. Radiology Ped. Rehabilitation Medicine Ped. Rheumatology Ped. Surgery Ped. Urology Pediatric Specialist, Abuse Pediatrics Perinatology Periodontics Physiatry Physical Medicine Physical Therapy Physician Assistant Plastic Surgery Podiatry Preventive Medicine Proctology Psychiatry Psychology Psychotherapy Pulmonology Radiation Oncology Radiation Therapy Radiology Reconstructive Surgery Rehabilitation Medicine Rep. Endocrinology Reproduction / Infertility Respiratory Therapist Rheumatology Sexual Abuse Counseling Sleep Disorders Sleep Medicine Social Work Speech Pathology Speech Therapy Sports Medicine Surgery Therapeutic Optometry Thoracic Surgery Toxicology Transplant Surgery Urogynecology Urology Vascular Diseases Vascular Surgery   

How many patients are seen in a typical week?

   

What percentage of patients visit more than once a month?

-- 0 - 20 % 21 - 40 % 41 - 60 % 61 - 80 % 81 - 100 %   

On average, how much time do patients spend in the waiting room?

-- 1 to 5 minutes 5 to 15 minutes 15 to 40 minutes 40 minutes or more   

Number of Waiting Rooms:

   

Number of Examination Rooms:

   

How many full time physicians work at this office?

   

How many part time physicians work at this office?

   

How many physician assistants/nurse practitioners/other work at this office?

   

 

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ECCO
1100 First Avenue, Suite 100
King of Prussia, PA 19406 U.S.A.

P:800.973.1728 (ext. 4146)
F: 484.636.0207
E: info@eccodocs.com