Administrative information

*Which system do you use for maintaining your clinical records? (If you use a non-EHR system, like Google, Microsoft, or paper choose the last open and describe.)

*What company covers your malpractice insurance?

*Please provide your malpractice policy number

If anyone assists you with administering your practice (eg scheduling, billing, insurance submission), list assistant’s name, email address and phone number

*Office arrangement

Provided as part of a group practice

Rental or lease

Office is owned by me or is in my home/apartment which I own/rent

Provide the name and email address of the landlord (i.e., person/company you pay for your commercial office space)

How did you hear about TheraClosure? Please try to be specific, such as naming the specific webinar, podcast, media story, conference, or Google search

Administrative information about your practice