Private Practice Consultation Questionnaire

Full Name *

Please type your full name.

Credentials:

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E-mail *

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Phone *

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Business Name

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Business Address

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Website (if applicable)

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Facebook or other social media page (if applicable)

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Reason for consultation (mark all that apply)

Billing/Insurance/Credentialing Leaving a group practice Starting a private practice Marketing/branding Practice management (organization, documentation, operations, etc.) Feedback on current website, marketing materials, office space, etc. Expanding an existing practice Other Invalid Input

Other (please describe):

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Which reason above is top priority?

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Please provide any relevant details for any items your marked above

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