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Contact Information
Name
*
First
Last
Mailing Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
Preferred Method of Contact
*
Phone
Email
Practice Information
Practice Name
*
Practice Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Year Established
*
Number of Operatories
*
Square Feet
Estimated Revenue
*
Please Select
Less than $500,000
$500,000 - $750,000
$750,000 - $1,000,000
$1,000,000 - $1,500,000
Greater than $1,500,000
Do you have partner(s) or associate(s)?
Yes
No
How many partners or associates?
Payor Mix (select all that apply)
*
FFS
PPO
HMO
Medicaid
What percent is Fee For Service?
What percent is PPO?
What percent is HMO?
What percent is Medicaid?
Condition of Equipment
*
New/Modern
Good/Dated
Needs Updating
Type of X-Ray
*
Digital
Conventional
Patient Records
*
Digital
Paper
Ability to commit to staying 2+ years?
*
Yes
No
Maybe
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