Your entries can be downloaded for offline edits — upload to submit.

Upload Filled Form (.xlsx)

Practice Information

Practice Name*

Practice Pronunciation (if non-obvious)

Helps the voice agent get it right if it's uncommon

Short Name*

Short Name Pronunciation (if non-obvious)

Helps the voice agent get it right if it's uncommon

Practice Phone*

Practice Email*

Used for business communications and portal access

Website

Scraped to build knowledge base for voice agent

Address

Timezone*

Scheduling Rules

Consultation Fee ($) — set to 0 for free*

Patient cost for consultations

Consultation Fee Applies to Procedure?

Does consultation fee go towards an eventual procedure?

Consultation Appointment Duration (min)*

Default length of a consultation

General Appointment Duration (min)

Default length of a general (e.g., follow-up/med-spa) appointment

General Appointment Availability

Practice-wide default for general (e.g., follow-up/med-spa) appointments

General Start Time

General End Time

Appointment Types*

In-person, virtual, or both

Same-Day Booking?

Whether bookings are allowed the same day as the call

Cancellation Policy

What the voice agent conveys as a cancellation policy if callers inquire

Providers

A $300/month fee applies for each provider beyond the first. Additional providers (up to 10) can be added later from the portal Configuration tab.

Provider 1 (primary)

Information

Salutation*

How the voice agent should refer to the provider

First Name

Last Name*

Last Name Pronunciation (if non-obvious)

Helps the voice agent get it right if it's uncommon

Pronouns

Provider Email

May match the practice email

Sees all General (unattributed) calls in their portal

Credentials

4D EMR Staff ID*

Numeric ID for the doctor in 4DEMR

4D EMR Facility ID*

Numeric ID for the facility/location in 4DEMR

Consultation Availability*

Days on which this provider gives consultations

Start Time*

End Time*

Use the practice's general-appointment availability

Social Media Handles

YouTube

Instagram

TikTok

Facebook

Twitter / X

Coordinators

Additional coordinators (up to 10) can be added later from the portal Configuration tab, where you can also set their level of call log access.

Coordinator 1 Name

Coordinator 1 Email

Coordinator 2 Name

Coordinator 2 Email

Coordinator 3 Name

Coordinator 3 Email

Voice Agent

Agent Name*

Agent Tone

The behavior you want the voice agent to reflect

Personality Notes

Any specific personality traits or instructions for the voice agent?

Knowledge Base

For rapid voice agent reference; rest is extracted from website and social media

Procedures Offered

Practice Specialties

Financing Options

Insurance Accepted

Additional Notes

Technical Configuration

VAPI API Key*

From app.vapi.ai → Account → API Keys

VAPI Phone Number ID*

From app.vapi.ai → Phone Numbers

4D EMR Client ID*

Your Client ID from 4DEMR

4D EMR Client Secret*

Your Client Secret from 4DEMR

Business Associate Agreement

Required before we can handle any patient information on your behalf. Your practice is the HIPAA Covered Entity; Simple Optimum Solutions acts as your Business Associate.

Please review the Business Associate Agreement (PDF) — it governs how we protect, retain, and return the patient information processed by your voice agent.

Legal Entity Name*

The legal business name of your organization

Signer Full Name*

The person authorized to sign on behalf of the practice

Signer Title*

e.g. Owner, Administrator, Managing Physician

I have read the Business Associate Agreement and, as an authorized representative of this practice, I agree to its terms on the practice's behalf. I understand this constitutes an electronic signature. *

We record the date and time, your IP address, and the exact version of the agreement you accepted.