Thank you for your interest in the U.S. HealthWorks clinic acquisition program.
Please complete the online form below and our Business Development department will you soon:
Practice Name:
Practice Street Address:
Practice City/State/Zip:
Practice Owner:
Name of Person completing this form
(Practice Representative):
Is the Practice Owner a physician?
Composition of Practice (check all that apply):
Number of Office Locations:
Approximate Annual Collections (for last 12 months):
Email Address of Practice Owner or Representative:
Daytime phone of Practice Owner or Representative:
Preferred means of :
Comments or Specific Instructions for U.S. HealthWorks Business Development Representative: