Internal Use Only: Locum Request Order

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Contact Information

First Name:

Last Name:

Email:

Mobile Phone:

Practice Information

Practice Name

Practice Phone

Address Line 1

Address Line 2

City

State

Zip Code

Office Contact

First Name:

Last Name:

Email:

Mobile Phone:

Reason for Coverage

Practice Type

Techniques










Write in specific technique(s)?

Opportunity Cost

Which days of the week are you open?

How many hours per day?

What is the average Patient Visits (PV) per day?

What is your average collections per PV?

Step 1: Between what dates will you need a locum?

Step 2: Define the days of the week you'll need a locum.

Day Of Week Daily Interval # of Visits







Promo Code:

Step 3: Opportunity Cost Calculation

(Patients Visits per Week (Add PVs for M- T- W- TH- F- S- S))
X Average Collections per Visit
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= Total Collections Per Week (or period of time they expect to need a Locum)

Step 4: Preview Order