In-Service Request

FIRST NAME AND LAST NAME *

TITLE (PT, OT, ETC.) *

HEALTHCARE NETWORK *

CLINIC NAME *

ADDRESS *

Address Line 1

City

State

Zip Code

WORK EMAIL *

PERSONAL EMAIL FOR UPCOMING EVENTS *

HOW MANY NEW UPPER EXTREMITY PATIENTS DO YOU SEE ON AVERAGE PER MONTH? *

HOW MANY NEW LOWER EXTREMITY PATIENTS DO YOU SEE ON AVERAGE PER MONTH? *

WHAT PERCENTAGE OF YOUR PATIENTS HAVE COMMERCIAL INSURANCE AS THEIR PRIMARY PAYOR? *

HAVE YOU OR DO YOU REFER LYMPHEDEMA PATIENTS TO MZ CUSTOMFIT?

ARE THERE ANY COMMENTS YOU WOULD LIKE TO SHARE ABOUT MZ CUSTOMFIT’S TEAM OF PATIENT ADVOCATES THAT WE CAN SHARE WITH OTHER LYMPHEDEMA CLINICIANS ON OUR HOME PAGE?

IF YOU DON'T MIND SHARING, WHICH PROVIDERS DO YOU CURRENTLY REFER COMMERCIAL INSURANCE TO?

IF YOU DON'T MIND SHARING, WHICH PROVIDERS DO YOU REFER PRIVATE PAY TO?

NOTE: WE ARE IN THE PROCESS OF LAUNCHING A PRIVATE PAY WEBSITE HOWEVER IN THE INTERIM, PLEASE NOTE THAT WE OFFER PRIVATE PAY PRICING.

ADDITIONAL COMMENTS

In-Service Request

Upload Your Documents

Quick Links

Contact Information