Clinic Intake Form
Clinic Owner's Name
*
First Name
Last Name
Clinic Owner's Email
*
example@example.com
Clinic Owner's Phone Number
*
Please enter a valid phone number.
Clinic Name
*
Clinic Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMR in use
Number of Physicians Needed
Physician Projected Start Date
*
-
Month
-
Day
Year
Date
What type of physician are you looking for? (Walk-In, Family Practice, etc.)
*
Clinic Volume
*
Please Select
High (45+)
Moderate (20-35)
Low (0-20)
New Clinic
Payment Model
*
Hourly Guarantee
Split Model
Both
Hourly Guarantee (CAD/hour)
Split to Physician (%)
Split to Clinic (%)
Any additional incentives you are willing to offer the physician?
Submit
Should be Empty: