Set up an in office program



Name of Contact Person:  


Email Address:


Office Name:


Do you have multiple offices you practice in?  YES NO


Locations:


Number of Doctors in your practice?


General/Specialty Practice?  YES  NO

              If yes, what type?  


Have you billed medical insurance in the past?  YES NO

  1. If yes, what were your results like?
  2. Would you say you were successful in obtaining medical reimbursement?

Any additional things you think we should know?