Membership Application
To apply for membership please complete all questions. If you are accepted, an additional questionnaire will be sent to you to complete your membership.
OWNER
*
First Name
Last Name
OWNER EMAIL
*
OFFICE MANAGER
First Name
Last Name
OFFICE MANAGER EMAIL
example@example.com
MAIN Practice Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
NUMBER OR LANES:
*
Do you have an office manager
*
YES
NO
Practice Website
*
Practice Phone Number
*
Format: (000) 000-0000.
TOTAL Practice Volume
*
< $700,000
> $1,000,000
> $2,000,000
> $3,000,000
> 4,000,000
Other
Cost of Goods %
PaYROLL %
FIXED COST %
OWNER NET %
PlEASE UPLOAD YOUR P&L for the last 3 YEARS
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How many locations ?
*
How many patients do you see a day, per OD
*
Do you have a specialty (i.e., CL, dry eye, etc.)?
How far out are you booked in advance?
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PRACTICE GOALS
What are your top three goals for the practice (not yourself).
GOAL 1
*
GOAL 2
*
GOAL 3
*
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PERSONAL GOALS
What are your top 3 personal goals
Goal 1
*
Goal 2
*
Goal 3
*
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General Questions
Please complete the following questions.
ARE YOu (or your office manager) WILLING TO HAVE A SCHEDULED MONTHLY CALL WITH A CONSULTANT?
*
YES
NO
Are you willing to require your staff to attend a monthly virtual mastermind
*
YES
NO
Are you interested in attending ROUNDTABLES OR MASTERMINDS?
*
YES
NO
IF SO, WHERE YOU LIKE TO SEE THESE EVENTS HELD, and HOW LONG DO YOU WANT TO SPEND AT AN EVENT IN A DAY.
If we told you that you had to fire or demote your office manager would you do it for good reason to achieve your goals.
*
YES
NO
DO you have an exit plan from your practice
*
YES
NO
Are you prepared financially to retire? Do you have a 401K, Investment property, etc...
*
YES
NO
Other
PATIENT RETENTION RATE:
PREAPPOINT RATE:
LIST STAFF MEMBERS, POSITION, SCHEDULE & SALARY
PLEASE LIST YOUR VISION PLANS
DO YOU USE ANY OF THE FOLLOWING:
SOLUTION REACH
4 PATIENT CARE
ADP
EYECARE PRO
EDGE PRO
FINANCIAL PLANNER
401K PLAN
DO YOU EDGE YOUR OWN LENSES
YES
NO
NO, BUT WOULD LIKE TO
IF WE TOLD YOU TO FIRE OR DEMOTE YOUR OFFICE MANAGER OR ANY OTHER EMPLOYEE T ADVANCE YOUR GOALS, WOULD YOU DO IT?
YES
NO
Signature
*
Submit
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