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

First NameLast Name
Business Owner Email Address and Website*

Email AddressWebsite URL
Owner Mobile Number*
Please enter a valid phone number.Format: (000) 000-0000.
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
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:
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?
Staffing Requirements
1) Do you have medical 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 Imaging services?*
4) What is the total number of full time staff?
Should be Empty:

Clinic Pre-qualification Intake Form

Business Owner and Location Information Page

Clinic Pre-qualification Questionnaire

Clinic Information

Staffing Requirements