Proposal Request for Medical Facility Appraisals

To receive a proposal for our services, please complete the questionnaire below.

If you have any questions, please call (800) 624-9993.

Medical Facility Name:

Contact Person:

Contact Person's Title:

 

Email Address:

Mailing Address:

   

City:

State:

Zip Code:

Phone Number:

Fax Number:

 

Number of Physicians:

Number of Physician Assistants:

Total Number of Employees:

Number of Beds:

Number of Surgery Rooms:

Number of Recovery Rooms:

Number of Speciality Services:

Number of Speciality Equipment

X-Ray:

MRI:

Ultra Sound:

Microwave:

CAT Scan:

Number of Physical Therapy Clinics:

Number of Pharmacies:

Yes
No

Is there a list of equipment available?

Number of Satellite Locations:

Square Footage:

Yes
No

Leased?

 

List of Departments: