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About Your Practice

Section 1 of 3

Practice / Organization Name*

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Specialty*

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Number of Locations*

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Approximate Number of Employees*

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City*

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Zip Code(optional)

Your Contact Information

Section 2 of 3

Your Name*

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Your Title / Role*

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Email Address*

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Phone Number*

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Best Time to Reach You*

Morning (8am–12pm) Afternoon (12pm–5pm) Either

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Preferred Contact Method*

Phone call Email

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Your Compliance Situation

This helps us prepare before we call.

Do you currently have a compliance program in place?*

Yes — fully maintained Partially — some things are in place No — starting from scratch Not sure

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When was your last HIPAA Security Risk Assessment (SRA)?*

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Are your staff HIPAA training records current?*

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Are all your vendor Business Associate Agreements (BAAs) current?*

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What is your biggest compliance concern right now?(optional)

How did you hear about Sentinel?*

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Anything else you'd like us to know before we talk?(optional)

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