Demo Doctor Questionnaire for the BAX3000 Program

Please print this questionnaire, fill it in and fax it to (561) 793-5311. Once we receive it, we will get back to you within 48 hours. Thank you for your willingness to help us promote this exciting new equipment to your peers.

 

 

If you could earn up to $5,000 for each successful demo performed:  Do you have a staff member we could train, who would have 1-2 hours a week to demo our equipment? Yes ____  No _____

 

How many hours a week would he or she have to dedicate to this? __________

 

 

If you could earn $500 for 30 minutes of your time answering questions about our equipment with other physicians who are considering purchasing it, would you have the time? Yes _____  No _____

 

How many hours a week could you devote to this? __________

 

 

Approximately how many patients do you see per week who suffer from allergies, asthma, eczema, Rosacea, Chronic Fatigue Syndrome, headaches, migraines or other substance-specific stress-related conditions? __________

 

 

Given the fact that we may be liable for your actions, we will also be doing a background check with the Board of Examiners in your state.  To your knowledge, are there are any Board complaints, actions or malpractice suits against you? If yes, please list them here:

 

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Lastly, credit worthiness is important in determining who we choose to participate in our Demo Doctor Program. Please list and explain any bankruptcies (what year?), delinquencies (how many and how long), and judgments or tax liens (for what, when and how much).

 

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When would be the best day and time to call you:  Date ______________________  Time: _______________________________

 

What is the secret password to actually get through to you? ________________________________________________________

 

 

Doctor's Name: _________________________________________________ Specialty: __________________________________

 

Address: _________________________________________________________________________________________________

 

Phone: _______________________ Fax: _______________________ Email: __________________________________________

 

 

 

NOTE: If you don't think this will work for you, is there someone you would like to recommend?

 

Name: ____________________________________ Phone Number: ____________________________

 

 

 

 

Please fax Questionnaire to: (561) 793-5311