Practice Consulting RFP - Practice Set-up


Practice Consulting -- Request for Proposal
 

Practice Name:
Physician Name:
Contact Name:
Address:
City:
State:
Zip:
Other Locations?
If so, how many?
Distance from location listed above:
Phone Number (please include dashes):
Fax Number:
Other Number:
Email Address:
Specialty:
Total Number of Providers:   MDs
  DOs 
  PAs
  NPs
   
How did you hear about our services?  
(If from another physician, please give their name)     

   
Do you have a Texas license?  
                                    
   
Are you a TMA member?  
                                    
   
Service Requested:  
   
Target Opening Date:
   
Are you being recruited?  
                                    
   
Hospital:
   
Comments:  
 
          

 

 

 

  

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