POTENTIAL PARTNER SURVEY
Company Name
*
Contact Email
*
example@example.com
Company Contact Name
*
First Name
Last Name
Contact Position (Title)
*
Contact Phone Number
*
-
Area Code
Phone Number
What type of organization are you?
*
Hospital
Health Clinic
Health System
Private Practice Clinic
Urology Clinic
Federally Qualified Health Center
Critical Access Hospital
Insurance Company/Payer
Locums / Staffing Company
Other
Where is your organization located? (City, State, ZIP)
What type of partnership are you seeking?
Joint venture or revenue-sharing model
Urology Telemedicine integration
Value-based care initiatives
Other
Are you interested in exploring new revenue streams through urology partnerships
Yes
Notes:
Submit
Should be Empty: