Wufoo

Clinic Slides Form

You can use the DHN CLINIC SLIDES to communicate your own custom-made message to your patients while they wait. Many of our doctors and diabetes professionals use the time to talk about their nutrition tips, exercise recommendations, or forms that need to be filled out before the doctor is seen. This way, you can save time and educate patients while they're waiting!

Only the name of your clinic is required information, you can enter as much of the other data as you wish. Once you complete your form, your customized segment will be uploaded into your DHN TV programming and will play once every 15 minutes.

If you have any questions, please call your Member Services Representative.

"Welcome to..." *

Submit the name of the Doctor or the Practice that you would like the Clinic Slides to be branded with.
Contact Information

Please only submit what you'd like displayed on your screen for your patients to see.
Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Please input the you'd like displayed on your screen.
Office Phone Number ### - ### - ####
Fax Number ### - ### - ####
Email Address
Hours of Operation

If you have a lunch break in between, please make a note in the "Special Notes about Hours" field.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Special Notes about Hours
Information for Patients

You can enter as much or as little information as you'd like. You can also create your own headings - these are just suggestions.
Health and Lifestyle Section (eg: Diet, Exercise, Target Levels, etc.)

You can use this segment to tell patients about your diet & exercise reccomendations. Spinach anyone?
Practice Information (eg: professional history, staff profiles, etc.)

Please list information about your clinic's doctor. This can include areas of study, continuation of studies, achievements and awards, or any general information you'd like your patients to know before they enter the examination room.
Patient Reminders (eg: insurance, classes, lab work, etc.)

Please list up to three reminders you would give to patients: for example, "Please have your insurance information ready before coming to the receptionist," or "Schedule a checkup every three months," or "The Doctor accepts donations of baked goods from grateful patients."
Other (you can include any other information here)

Please use this space to display any other messages you would like patients to see while they wait.
Feedback

Please tell us how we can improve this form!
Do Not Fill This Out

Wufoo

Contact Information

Hours of Operation

Information for Patients