Medical Wishlist

1
What type of business are you?Select multiple if you are a multi-disciplinary business
Dental
General Practice
Family medicine
Dermatology
Physical Therapy
Chriopractic
Pediatrics
Orthopedic
Urgent Care
Massage Therapy
Other
2
Name
First Name
Last Name
3
Email
example@example.com
4
Address of the business
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Phone Number
Area Code
Phone Number
6
How did you hear about us?You can select more than one!
Google
Facebook
My Coach
A Colleauge
Youtube
Pinterest
Linked IN
7
What is your target start date?
How soon do you want to make these changes
8
When are you looking to have the project completed?
9
How many staff members do you have?Not including yourself
10
What is the size of your current facility?Approximately how many sq ft?
11
What are you struggling with the most on a day to day basis?For example are you feeling frustrated that the staff isn't following directions? Are your patients sucking too much of your time? Do you need help just looking at the overall day to day business side of the practice? You don't really know where there is an issue and just need an expert to help point you in the right direction.
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Small
Ok
Ok
12
Do you have any particular questions you want answered?
13
Do you own your current facility?
YESNO
14
What is your primary purpose for reaching out?Select all that apply
COVID Response
Expansion
Relocation
To determine if I should stay or move
Consolidation
New Practice
Second Location (Satellite office)
Franchise
Remodeling
Growth
Adding additional services
Integrating new services
Increased volume
Efficiency
More focused staff members
An office to support my systems
Operational Effectiveness
15
Do you lease your current facility?
YESNO
16
If there was one item you feel is currently holding you back the most... What would it be?For example: My office isn't designed to properly support my goals and is an embarrassment to walk into everyday.
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Large
Normal
Small
Ok
Ok
17
Which of the below products do you feel will best help you achieve your goals?You can select more than one!
Goal oriented Facility Design program
Redesigning for COVID guidelines
Experiential Office Design
Modular Workstations designed for my teams systems
Interior Design
Business coaching
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