MedNexus Location Intake Form

Clinic Pre-qualification Intake Form
MedNexus Health Contact:
(fill in the Representative name here, ie. first point of contact)
Referred by:
(fill in the Referring Party if applicable, ie. channel partner, Rep, or individual
Business Owner and Location Information Page
Legal Business Name (Single Clinic, Parent Company or Formal Entity)blanks
(Please add formal business name in the blank space above)
Legal Business Address (physical or mailing)*

Street Address

Street Address Line 2

CityState

Zip Code
9 Digit Tax ID #*
To verify your business
9 Digit D-U-N-S #. (if available)
If applicable
How many clinics do you own?

Single ClinicMultiple Clinics
If multiple clinics, please enter total locations below:
Business Owner Name*

First NameLast Name
Business Ownership %*
Business Owner Email Address and Website*

Email AddressWebsite URL
Owner Mobile Number*
Please enter a valid phone number.
Clinic Physical Location Address: (if multiple clinics please submit in last section)*

Street Address

Street Address Line 2

CityState

Zip Code
Clinic Main Phone Number*
Clinic Main Email Address*
example@example.com
Clinic Manager Name

First NameLast Name
Clinic Manager Contact Info

Direct Phone or MobileEmail Address
Clinic Pre-qualification Questionnaire
Clinic Information
1) Type of Clinic: (check all that apply)

Integrative ClinicUrgent CarePersonal Injury ClinicChiropracticDentistPediatricAcupunctureOrthopedic ClinicMed SpaImaging CenterFamily PracticeSurgery CenterPain ClinicPhysical Therapy ClinicHospital FacilityIndependent Practice in Medical ComplexMedical CampusOther
2) Please describe a list of services that your location provides:
3) What is the clinic total gross revenue for last year?
4) What is the clinic EBITDA for last year?
Earnings Before Interest, Taxes, and Amortization --Profitability: Cash flow: Efficiency: Risk: Growth:
5) Are your tax returns prepared and signed off by an accountant?
6) Total client/patients per month?
Example: 100 patients per month
7) How many cash pay client/patients per month?
Example: 65 patients are cash pay
8) How many client/patients insurance billings per month?
Example: 35 patients are insurance billables
9) Do you have a 12 x 15' Room Available?
Space requirements: 10' x 12' is the minimum space
10) Does your location have a current lease in good standing?
If yes to above question: How long is the lease at your current location?
If No to above question: Are you planning to renew or relocate and what is timing?
11) Have you or the business filed bankruptcy within last 7 years?
12) Does the clinic have any other current or prior litigations?
If not leave blank. If yes, please specify in detail above:
13) Does your state require licensing and certifications for radiology safety?
14) Please disclose and expand on your states regulations in a description here:
Staffing Requirements
1) Do you have staff onsite to operate SeeFactor CT3?*
ie. Licensed Radiology Technician, MD, Physician
2) How many licensed healthcare professionals on staff? If so, how many and what are their certifications?
3) Do you have an available receptionist on staff full time for Envigor8 services?*
4) What is the total number of full time staff?
Clinic Financials & Support Docs Uploads

To support placement eligibility, clinics are required to submit accountant-prepared and reviewed year-end financial statements for the past two years. Audited statements are not necessary; however, financials must be professionally compiled and formatted according to standard accounting practices, including a balance sheet, profit and loss statement, and supporting notes.
1) Corporate Tax Returns: Provide corporate tax returns for the past two years, prepared and reviewed by a licensed accountant.

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2) Year-End Financials: Provide year-end financial statements for the same two years, accountant-prepared and reviewed. Audits are not required. Statements must include a balance sheet, profit and loss, and standard notes to support financing approval.

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3) Upload (+/- Personal Tax Returns - Last 2 Years)

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4) Upload (Current Year P&L)

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4) Upload copy of competed W-9 Form

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5) If Multiple locations Upload PDF with point of contact details and clinic info here:

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6) Upload W2s for all Personal/ Clinic Guarantors (clinic ownership partners)

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Should be Empty:

Clinic Pre-qualification Intake Form

Business Owner and Location Information Page

Clinic Pre-qualification Questionnaire

Clinic Information

Staffing Requirements

Clinic Financials & Support Docs Uploads