IT SUPPORT TICKET
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Date
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:
Hour
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Minutes
AM
PM
AM/PM Option
Level of urgency:
*
Low
Medium
High
Critical
Your Name:
*
Office Name:
*
Your Name:
Supplies and Quantity Needed:
Email and/or Callback Number:
*
Issue type:
*
Computer Issue
Printer Issue
Phone/Internet Issues
EMR Interface Issue
Client Portal Issue
Password Reset / Locked Out
Description of Issue:
Upload screenshot and/or Document:
Submit Ticket
Description of Issue: (No PHI)
Should be Empty: