Client Survey

Please take a few moments to complete our survey. The information that you share with us is privileged and confidential and will be used to develop an agenda for our visit.
  • Name# Years in Practice 
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  • CONTACT INFORMATION

  • NameEmail 
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    Please provide the email address of any doctor who would like to be sent follow‐up information.
  • PRACTICE INFORMATION

  • LocationDays Per MonthDistance from Main OfficeConnection TypeConnection Speed 
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    If you have multiple office locations, please list and describe the method by which they are connected (DSL, cable modem, T1 line, etc.) and speed of that connection (1 MG upload / 4 MG download). Start with the Main office.
  • Position / TitleStaff Member Name# Years in Practice 
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    List positions including Office Manager, Treatment Coordinator, Scheduling Coordinator, Insurance Coordinator, and Financial Coordinator.
  • Do you use a bookkeeper or an accounting firm for the following services?
  • Position / TitleStaff Name# Years in Practice 
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    List clinical positions including Clinical Coordinator, Clinical Assistant/RDA, Lab Technician, and Records Technician.

  • TREATMENT MECHANICS
  • SOFTWARE

  • IMAGING

  • HARDWARE / TECHNOLOGY

  • Individual or Company NamePhone #Are you pleased with their services? 
    Add a new row
  • FINANCIAL INFORMATION

    *Please send current fee sheet

  • FEES
  • MISCELLANEOUS

  • This field is for validation purposes and should be left unchanged.
 
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