Location Verification

What is the official name of your practice?

What was the name of your practice before the rebranding?

What is the physical address of your practice (not the mailing address)?

If applicable, provide the name of the suite, floor, level, building, campus, and/or complex your practice is located at

City or Town

State

ZIP Code

Primary phone number for this practice

If you have an alternate phone number, such as toll free or to your scheduler, please list it here

Fax number for this practice

What are your hours of operation? This should be the consistent hours when your phones are being answered by staff and not when the providers are at your location.

Who is the primary point of contact we can work with on a regular basis to maintain web content accuracy at this practice?

Phone number for this point of contact

Who would you like to be able to edit the webpage for location (we encourage more than one person)?

Is there an email we should direct messages to from patients about your practice?

Please list the names of all the providers that should be displayed on your practice's web page

Please select the services you provide at this practice location

Please enter any services that are not listed above

Please select the appropriate amenities for your practice location

Please select which accessibility features are available at your practice's location

Anything else you would like to add about your practice? Such as, what differentiates your practice from your competitors? Why should a patient use your practice location instead of the next nearest option? What makes your practice location unique?