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 info@harperozone.com.

    -----------------------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.)

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