Facilities Profile Form

Sales Rep *

Email Address *

Name of Facility Network *

Corporate Address *

Number of Locations *

Lead Location (State) *

Other Locations/Branches (States) *

Facility Contact Person *

Role *

Facility Contact Email *

Facility Contact Phone *

Type of Facility * Type of Facility * Skilled Nursing (SNF) Hospice Home Health (HH)

(SNF) Number of Beds *

(SNF) Occupancy Rate *

(SNF) Number of Wound Patients *

(Hospice) Number of Total Patients *

(Hospice) Number of Wound Patients *

(HH) Number of Total Patients *

(HH) Number of Wound Patients *

(Insurance Mix) What would you estimate to be the percentage of traditional/straight Medicare? * (Insurance Mix) What would you estimate to be the percentage of traditional/straight Medicare? * Less than 75% Less than 50% Less than 25% More than 25%

Currently working with a Wound Care physician or agency? * Currently working with a Wound Care physician or agency? * Yes No

If yes, what company? *

Do they offer debridement? Skin subs? *

Are they working with a Medicare Part B DME supplier? * Are they working with a Medicare Part B DME supplier? * Yes No

If yes, what company? *

What type of EHR does the facility/branch utilize (e.g. Point-Click-Care)? *

Wound Pros Presentation Request (Please provide 3 DATE/TIME options.) *

Others attending Zoom meeting (Please provide their first & last name, title and email.) *