General Information

Your Name *

Email *

Phone *

Who Referred You to Us? *

Practice Name *

Practice Address(es) (List All Locations) *

Practice Phone *

Practice Email *

Head Practitioner (Client) Name and Email

Head Practitioner (Client) Cell Phone Number

Office Manager or Point of Contact Name(s) and Email(s)

Associate Practitioner or Partner Practitioner Name(s) and Email(s)

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Practice Information

Do you have a separate room or space for shockwave?

Do you already have your shockwave device? If yes, how long have you had it. If not, what date do you anticipate receiving it? *

Please list your fees for services. *

What were your gross collections last year?

What are your estimated collections this year?

Are you in-network with Tri-West insurance?

Are you currently part of or have you been part of a practice management group previously, and if so, what group?

Are you currently offering nutritional supplements and if so, through what company?

Are you currently offering other therapies and if so, what therapies?

Do you have a corrective care and/or maintenance care practice?