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Fax:1-626-408-6624
Email:info@neurolinkdx.com

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Name of Doctor:
Contact Person:
Address:
City
State
Zip Code:
Office Phone:
Direct Phone:
Fax:
Email:
What type of Doctor are you?
Please check all that applies:
	Please contact me so I can get started on the Program. Please contact me so I can learn more about your Program. Please send me more information.
Preferred form of correspondence?
	Phone Email Postal Mail
Questions for Potential Clients (Optional)
What state do you practice in?
Demographics of Patient Providers:
	% Private Insurance % Workers Compensation
	% Personal Injury % Medicare/Medicaid
What type of diagnostics utilized in your office (check all that apply):
	X-ray Ultrasound MRI CT Scan R.O.M.
Have you ever had an EMG or NCV performed in your office?
	Yes No
Have you ever had a Neurologist or Physiatrist in your office?
	Yes No
Have you used a mobile diagnostic service before?
	Yes No