Practice Profile Form

Sales Rep *

Email Address *

Clinic Name *

Owner Name *

Signing Physician *

Title * Title * DPM MD DO PA NP

NPI # *

Specialty *

Key Clinic Contact *

Email *

Phone Number *

Address *

Number of Locations *

Number of Doctors (including mid-level) *

Payor Mix: What percentage is Commercial? *

Payor Mix: What percentage is Medicare (Part B)? *

Payor Mix: What percentage is Tricare? *

Payor Mix: What percentage is Advantage? *

How many Total Patients does the Practice treat per month? *

How many Medicare (Part B) Patients does the Practice treat per month? *

What percentage of your Medicare Patients have Supplemental Plans? *

Who handles your billing? * Who handles your billing? * In-house Outsourced to a third party

Are you currently doing Wound Care in your clinic? * Are you currently doing Wound Care in your clinic? * Yes No

If yes, are you using Skin Subs (Amniotic Membrane)? * If yes, are you using Skin Subs (Amniotic Membrane)? * Yes No

If yes, what Skin Sub Manufacturer(s) have you used? *

If yes, how many Medicare Wound Patients do you treat per month? *

How many new Medicare Wound Patients do you treat per week? *

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

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