Perfect Practice Web NeuropathyDR® Membership Application
Client Fact sheet.
PLEASE FAX THIS FORM TO 774-516-1302
Or
Scan and email it to
I am accepting selected clinicians into my programs ONLY to help insure your success and the success of your patient care. So I really need to know you are committed to doing this, have the necessary basics in place and are willing to really help your patients. You will after all, be an extension of my work.
I am asking that you provide some information about yourself and I reserve the right to refuse your Application or to call and interview you before you are accepted. Any information you provide is, of course 100% confidential.
Name: ______
Practice or Clinic Name: ______
Street Address: (no PO Boxes)______
City ______State:______Zip ______
Best Phones C______H______O______
Fax ______
Email ______
If you would prefer to have your information mailed to your home address, please provide it here.
Home Address: ______
City ______State: ______Zip ______
Years in practice ____1-5 ___6-10 ___11-15 ___16+
__ Single office ___ 2 or more offices
Indicate which Ones You’d Like To License
__ Solo Practice ___ Group Practice
Staff:
__ Front Desk ____ years of employment
__ MA ____ years of employment
__ Business office ____ years of employment
Patient Care Techniques currently using:
___ Ultrasound
___ Interferential
___ Laser
___ Decompression/Traction
___ Other: ______
Current Fee Schedule Averages:
New Patient ______Routine OVs ______
Modalities ______Other Revenues______
Marketing Systems Currently in Use:
___ Newspaper
___ Radio
___ Mailing
___ Email
___ Facebook
___ Twitter
___ Web
What are you most satisfied with in your clinic?
___ Ideal Patients ___ Patients’ compliance
___ Marketing ___ Referrals from patients
___ Association with fellow docs___ Referrals from MDs
___ Stability of practice___ teamwork of staff
___ Personal Income___ retirement plan
___ Other: ______
What are you most concerned with in your clinic:
___ Ideal Patients ___ Patients’ compliance
___ Marketing ___ Referrals from patients
___ Association with fellow docs___ Referrals from MDs
___ Stability of practice___ teamwork of staff
___ Personal Income___ retirement plan
___ Other: ______
Why do you want to work with Neuropathy Patients and be the NeuropathyDR® clinic in your area?
___ Increase practice revenue
___ Attract a new type of patient
___ Be an important part of patients recovery
Why should we accept your application, and why would yours be a good reference clinic for us?______
______
______
What, and how often do you do stuff just for fun?
___ golf___ ski___ boating
___ fishing___read___ time with family
___ vacations___travel
___ other: ______
______
When and Where Are Your Next Vacations ______
- Please Attach basic office statistics on a per month basis for the last 12 mos. or further back if you can (not > 36Mos). Include NPs, OVs, Services, and Collections at a minimum. Any software printout is fine.
- What else should we know about your goals?______
Program and Licensing Level I Desire To Be Accepted into: ______
What else do We need to know????
______
PLEASE FAX THIS FORM TO 774-516-1302
Or:
Scan and email it to