May 14, 2008 ://design v2.2  
     

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All Fields Are Required Unless Marked as Optional
 
What is your current status?
Looking for an Associate  Wish to Sell Practice   Other 
If other, please explain:
Practice/Clinic Name    
       
Physician Contact Information    
First Name Last Name
Email    
Address    
City    
State Zip
Office Number Office Fax (optional)
Number of Physicians currently in Practice
Total Number of Offices
Total Number of Employees (other than physicians)
If seeking an associate, please complete the following:
 
Number of Associates Needed: Date Associate is Needed:
   
Is Practice Limited to Allergy? Number of Active Patients:
Yes   No
   
Practice Type: Type of Fellow Needed:
Adult   Pediatric   Both Adult   Pediatric   Both
   
Equity Position Available:  
Yes   No  
What type of practice do you have?
Solo   Association   Group   HMO   Multi-Clinic   Medical School Affliate 
Academic Only
   
What type of area is the practice located?
Major Metro area   Major Metro/Medium city   Medium size city
Medium city/Small town   Small town
   
Area Population (approx)
   
Additional information of value regarding this practice:
   
Do you want candidates to contact you directly?
Yes, indicate method below   No, keep my information confidential
   
If above is yes, please indicate how you wish to be contacted: 
 
 

 

 

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