Impireum Health Partnership Group Form

Impireum Health Partnership Form
PRACTICE INFORMATION
1. Practice Legal Name
1A. Have you used OTHER names?*

YesNoOther
1B. Other Name(s) used*

First NameLast Name
2. Current Location:

Street Address

Street Address Line 2

CityState

Zip CodeUSA
3. Phone Number*
4. Fax Number*
5. Specialty*
6. Years in Operations*
7. Current Patient Volume (Monthly)*
8. Number of Providers*
9. Practice Model

SoloGroupHospital-AffiliatedCorporate-OwnedOther
10. Service Offerings

Psychiatric ServicesPsychotherapy/CounselingAdvanced Treatments (TMS, Ketamine, Spravato, NeurofeedbackIV Therapy & InjectionsAesthetic & Regerative ServicesWeight ManagementHormone TherapyMassage TherapyOther
PARTNERSHIP INTERESTS
11. What partnership model interests you most?

Full IntegrationCollaborative AllianceSpace-SharingSpecialty Service ProviderOther
12. What attracts you to Impireum Wellness? (Select Top Three)

Integrated care modelAdministrative supportTechnology infrastructureRevenue growth potentialAccess to new servicesMarketing supportReduced overheadWork-life balanceOther
13. Which of our bundle services would complement your practice?

Weight + WellnessExecutive HealthMoodReset Programs (Depression/AnxietyNeuroFocus (ADHD)Men's VitalityMetabolic ResetTotalGlow AestheticsOther
14. Current Challenges (Select top 3)

Administrative burdenRevenue/reimbursement issuesPatient acquisitionStaff recruitment/retentionTechnology limitationsSpace constraintsWork-life balanceLimited service offeringsOther
FINANCIAL & OPERATIONAL
15. Annual Practice Revenue:

Under $500K500K−1M1M−2.5M2.5M−5MOver $5MOther
Insurance vs. Cash Pay Mix
16. Insurance: _____%
17. Cash/Self-Pay: _____%
18. EMR System Currently Using:Other: _______________None

eClinicalWorksEpicAthenaVagaroAdvancedMDNoneOther
GROWTH & VISION
19. What are your 3-year growth goals?
20. What new services would you like to add?
How many patients could you refer monthly for:
21. Psychiatric Services?*
22. Therapy Services*
23. IV/Wellness Services?*
24. Aesthetic?*
25. Weight Loss*
26. Others*
27. Timeline for Partnership Decision:*

Immediate (Within 30 Days)1-3 months3-6 months6+ monthsOther
28. Preferred Next Step:*

Schedule TourFinancial DiscussionMeet medical teamAll of the aboveReview partnership agreementShadow our operationsOther
29. Best contact information:*

eMailPhoneMeetingOther
🚀 START YOUR PARTNERSHIP JOURNEY

Three Simple Steps:

1. EXPLORE
Schedule a confidential consultation to discuss your goals and explore partnership options.

2. EVALUATE
Tour our facilities, meet our team, and review financial projections tailored to your practice.

3. ELEVATE
Join the Impireum family and transform your practice while improving patient lives.

💼 EXCLUSIVE PARTNERSHIP BENEFITS

First 10 Partners Receive:

Founding Partner Status with preferential terms
$25,000 Marketing Credit for practice launch
Priority Scheduling for shared services
Reduced Revenue Share for first year
Executive Health Membership for all providers

📞 READY TO TRANSFORM YOUR PRACTICE?

Contact Our Partnership Team:

Dr. Nadia McFarlane
Chief Medical Officer

partnerships@impireumwellness.com
(877) 631-0010 ext. 501

Holly O'Berry
Practice Administrator

hoberray@impireumwellness.com
(877) 631-0010 ext. 103
Should be Empty:

Impireum Health Partnership Form