Question 1Required

First, what’s your name?

We’ll know who we’re writing back to.

First name

Last name

Please enter your first and last name.

Question 2Required

What’s your work email?

This is where we’ll send our follow-up.

Please enter a valid email address.

Question 3Required

What’s your role?

Select the option that fits best.

A Administrator / Executive Director B Director of Nursing (DON) C Assistant Director of Nursing (ADON) D Medical Director E Owner / Operator F Regional / Multi-Facility Leader G Something else

Please select your role.

Question 4Required

What’s the name of your facility?

If you operate multiple, name your primary or parent organization.

Please enter your facility name.

Question 5Required

How many beds?

Approximate is fine.

AUnder 50 B50–99 C100–149 D150–249 E250+

Please select a bed count.

Question 6Required

What’s your current communication system?

Select all the methods your team uses today for provider–nurse communication.

1Personal text 2Text app 3Phone 4Email 5Fax 6Other

Please select at least one option.

Question 7Required

How many provider groups deliver care at your facility?

Approximate is fine.

A1 B2 C3 D4 EMore than 4

Please select an option.

Question 8Optional

Do you offer any specialty services?

Select any that apply.

1Dialysis 2Vent care 3Other

Question 9Optional

Where is your facility located?

City and state — helps us understand your regulatory and market context.

City

State

Question 10Optional

What are you trying to solve?

Select any that apply — we’ll come prepared. (Final list pending.)

1 Provider–nurse communication 2 Documentation & continuity of care 3 Risk reduction & defensible records 4 Operational efficiency 5 Replacing fax, paper, or text apps 6 Other

Question 11Optional

Anything else we should know?

A specific cycle that’s breaking down, a timeline you’re working against, who else should be in the conversation.