DOCTOR SURVEY/OFFICE EVALUATION

//DOCTOR SURVEY/OFFICE EVALUATION

DOCTOR SURVEY/OFFICE EVALUATION

This survey is intended to assist us in evaluating your current situation so that we may best determine your current needs and how we can help you make the most successful transition to the “Live to 139” program. Please answer the questions as thoroughly as possible so we get an accurate picture of where your practice is today, and where you want it to go in the future! This will help us design a custom roadmap for your journey!!

You can either fill out and submit the form below… or you can follow the link for a printable survey that you can fill out and email back to [email protected]

-----------------------OFFICE MAKEUP------------------------

Your Name (First & Last Name + Title required)

Your Email

Your Telephone #

Your Duties & Status (full time/part-time)

Other Practitioners/Credentials/Duties/Status (full time/part time):

Staff/Duties/Status (full time/part time):

Square Footage of office:

Number of Treatment rooms:

Clean Room/Hood/Mixing Station:

Number of seats in Reception area:

Lecture area/Seating/Equipment:

-----------------------FRONT DESK OPERATION/SERVICES OFFERED-------------------------

Office Overhead Cost/Daily/Hourly:

EMR or Paper Files?

Insurance based/Cash/Both?

Chiropractic Care?
YesNo

Nutritional Evaluation?
YesNo

Traditional Medicine?
YesNo

Rehabilitation services?
YesNo

Fitness/Conditioning?
YesNo

Lab work?
YesNo

Detox Program?
YesNo

IV Program?
YesNo

Cost per IV Procedure:

Hormone Therapy (Pellets, oral troches, injection, Creams):

Nutritional Supplements (products used & profit margin):

Joint Injections Cortisone/PRP/stem cells/other):

Bone/Fat/Stem Cells (products used):

Prolotherapy?
YesNo

Ozone Injections (solution used):

Sexual Health (conditions treating):

Cosmetics/Botox/PRP/Ozone/Hair Restoration/Micro Needling:

Do you have a referral network for services you don’t offer?
YesNo

Describe your current patient base:

-----------------------EQUIPMENT USED-------------------------

Ozone machine (make/model):

10 Pass/Zotsmann/Green Machine/UVB?
YesNo

Imaging Equipment/ CR Arm?
YesNo

Laser (make/model):

Ultrasound?
YesNo

PEMF/Beemer?
YesNo

Shockwave?
YesNo

EMS?
YesNo

OTHER?

-----------------------GROWTH POTENTIAL-------------------------

Are you interested in expanding services to existing patient base, acquiring new patients, or both?

Are satisfied with your current practice?

Do you envision expanding Staff, Services or both?

Where do you see your practice in 5 years?

Do you currently have an asset protection plan? If so briefly describe:

-----------------------GROWTH POTENTIAL-------------------------

List any additional trainings/fellowships you have done and the group you trained with (ozone, IV, Functional Medicine, Aesthetic, Sexual Health, etc.):

Click Here To Download Survey
By |2018-11-06T15:02:20+00:00November 1st, 2018|Uncategorised|Comments Off on DOCTOR SURVEY/OFFICE EVALUATION

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