Web Based Reporting Edits and Analysis Request Form

The Intermacs Report Team has developed this form to ensure all report inquiries are addressed in a timely manner. Please use this form to submit questions and comments about any of our reports.
For Example: Request edits in Intermacs or Pedimacs quarterly statistical reports, Ask any questions about our reports, Provide any feedback or Suggestions for the reports or customize analysis report request.
You will receive a confirmation email with a submission id number. Our team will follow-up when your request has been reviewed. The submission id number can be used to track the status of your request when contacting us.
First Name*
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Last Name*
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Hospital Site*
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Role*
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Other
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Email
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Subject
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Registry*
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Request*
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