Remember to use an Incogito/Private browser session when filling out this form. Contact Information First Name: Last Name: Email: Mobile Phone: Practice Information Practice Name Practice Phone Address Line 1 Address Line 2 City State 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 Zip Code Office Contact First Name: Last Name: Email: Mobile Phone: Reason for Coverage Maternity Vacation Growth / Capacity Issue Injury / Health Issue CE / Seminars / Professional Development Practice Type Family Wellness Pediatric Sports Rehab Personal Injury Acute Injury Upper Cervical Techniques Manual Adjustments Diversified Palmer Package Activator Arthro Stim Drops Soft Tissue (ART/Graston) Webster Technique TRT Write in specific technique(s)? Opportunity Cost Which days of the week are you open? Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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? Add a new date range Step 2: Define the days of the week you’ll need a locum. Day Of Week Daily Interval # of Visits Monday Full Day Half Day Tuesday Full Day Half Day Wednesday Full Day Half Day Thursday Full Day Half Day Friday Full Day Half Day Saturday Full Day Half Day Sunday Full Day Half Day Promo Code: Preview Opportunity Cost & Order Step 3: Opportunity Cost Calculation (Patients Visits per Week (Add PVs for M- T- W- TH- F- S- S)) X Average Collections per Visit ——————————- = Total Collections Per Week (or period of time they expect to need a Locum) Step 4: Preview Order Place Order
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