Physician Locator Authorization Form 500-007-02

Physician Locator Authorization

BHT Consumer Websites Physician Locator
Please complete the information below as you wish it to appear on the BHT Consumer website physician locator. Please complete one for each practitioner to be listed on the locator.
Practice / Facility Name*
Practice or Facility Name
Provider Name*

PrefixFirst NameMiddle NameLast Name
Languages Spoken
Provider Credentials (Please select all that apply)

M.D.FACSFAADD.O.Other
Medical Specialty
Practice Address (Additional locations? Please complete on form below)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Practice Website*
www.mypracticename.com
Practice Email
example@practicename.com
Patient Inquiry E-mail
example@example.com
Display Phone Number*

Area CodePhone Number
Clinical Applications Supported

FaceBreast ReconstructionBBLHandsHairBreast AugmentationOther
Products Supported

Serene Breast ImplantsPureGraftPureGraft Essence ADMDermaposeOther
CONSENT: The information below will NOT appear on the website locator, but is to be used for internal purposes:
Contact Name

First NameLast Name
Contact Email
example@example.com
Photo Display Permission: Please select YES to provide permission for us to display your headshot (from your website) next to your physician listing.

YES, Please DisplayNO, Do Not Display
I acknowledge and understand that having my practice listed on the Physician Locator may lead to prospective patients contacting my office with the assumption my practice offers procedures using Puregraft, Serene or other Bimini Health Tech products. I agree that participation on the Physician Locator is completely voluntary and if at any time I wish to terminate my participation, I will notifiy Bimini Health Tech in writing. Upon receipt by Bimini Health Tech of notification to terminate, my listing will be removed as soon as reasonably possible.

Questions or concerns? Please email Michele VonGerichten, mvongerichten@biminihealthtech.com

500-007-02_B
I authorize listing of my practice on the Physician Locator feature of the Consumer website.

Clear

Physician Locator Authorization

Please complete the information below as you wish it to appear on the BHT Consumer website physician locator. Please complete one for each practitioner to be listed on the locator.

CONSENT: The information below will NOT appear on the website locator, but is to be used for internal purposes:

Additional Locations - please complete here: