On-Site Practice Assessment Request

Your comprehensive on-site practice assessment includes one day in office and a dinner meeting.

  • Observe patient flow
  • Observe and evaluate patient experience
  • Sit-in and evaluate patient exam/ consultation and post-op (if applicable)
  • Review patient education materials
  • Evaluate patient education process
  • Evaluate exam to surgery conversion process
  • Review follow-up protocols
  • Review post-op experience and patient referral programs
  • Evaluate phone staff
  • Evaluate price presentation
  • Meet with and evaluate staff positions
  • Review staff morale and satisfaction
  • Review process challenges with management
  • Furnish comprehensive report citing all discoveries – challenges and opportunities
  • Furnish recommendation report with prioritized action points
  • Printing, binding and shipping of reports

    Name:

    Email:

    Phone:

    Practice:

    Practice City:

    State:

    Practice Zip:

    Services of foucus:

    LASIKCataractsDry EyeOpticalCosmeticsOther

    Number of Locations:

    Contact to confirm dates:

    Same as above

    Name:

    Email:

    Phone:

    Ideal days of the week for observation of consultation/exams:

    MondayTuesdayWednesdayThursdayFriday

    Preferred month of visit:

    Service Authorization
    $3,500 plus travel expenses

    Authorized By:

    Payment

    Pay by Credit Card

    Pay by Check*
    *I understand I will receive an invoice for the practice assessment and that the dates cannot be held until payment is reveived.

    Name on Card

    Card Number

    Expiration Date

    Security Code

    Zip Code

    Terms & Conditions: Payment is due at time of contract signing. Travel expenses due 15 days after completion of visit. If CLIENT changes or cancels consulting trip after travel arrangements have been booked, travel cancellation or change fees will be due. CLIENT is solely responsible for all advertising messages they approve produced for them by EYEMAX and agrees to fully defend, indemnify, and hold harmless EYEMAX for any claims, demands, liabilities, losses, suits, or actions arising out of EYEMAX’s services on behalf of CLIENT.

    Ready to Grow Your Surgery Volume?

    Contact Us