Questionnaire

Please complete the questonnaire below to have an Atlas Representative contact you.

* Indicates Required Information

About Your Practice:

Have you ever performed on-site electrodiagnostic testing at you practice?

How many patients per week do you refer out for electrodiagnostic testing?

How many physicians are in your practice?

How many locations in your practice?

What type of payer mix do you have in your practice?:*

General Insurance:	%
HMO:	%
PPO:	%
Worker's Comp:	%
Personal Injury:	%

About Yourself:

Name:

Dr. Name:

Specialty:

Address:

City:

State:

Zip Code:

Phone:

E-mail:

Comments:

Atlas will never share,sell or use information we collect with any other party or vendor

Atlas will contact you usually within 1 hour after we receive your information