1. Business Owner Information

Business Name *

First Name *

Last Name *

Email *

Phone *

What is your professional designation? *

Years in Practice

Number of Clinic Locations

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2. Team Structure

Total Staff Members *

Number of Providers *

Who will primarily perform SoftWave treatments?

Who will help introduce SoftWave to patients? (check all that apply)

What other licensed providers are in your practice such as NP, RN, ND etc?

3. Current Patient Volume

Average new patients per week *

Average total patient visits per week *

Which conditions do you treat most often? *

What percentage of your patients deal with chronic or recurring pain?

4. Current Services & Modalities

Which services do you currently offer? (check all that apply)

5. Business Model

Your clinic is primarily: *

Typical price for a specialty treatment session in your clinic (avg per visit)

6. Clinic Readiness

Has a treatment room or area been identified for the SoftWave device?

Yes

Who will oversee the implementation and launch of SoftWave in your clinic?

When do you hope to begin treating patients with SoftWave? *

7. Goals for SoftWave

What are your primary goals for adding SoftWave to your practice? (check top 2) *

Monthly Revenue goal from SoftWave treatments? *

Number of Treatments per month goal? *

What would success with SoftWave look like in 12 months? *

8. Opportunity & Mindset

On a scale of 1–10, how committed are you to successfully launching SoftWave in your clinic? *

What would help move you closer to a 10?

9. Biggest Challenge

Please select the top 2 biggest challenges currently facing your clinic?