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Mohs Surgical Coverage Inquiry

Thank you for your interest in direct Mohs coverage. The information below will help me better understand your practice, anticipated coverage needs, and scheduling requirements so that I can prepare a proposal tailored to the arrangement you are considering.

Section 1: Practice & Organization

1. What type of organization is seeking coverage?

A
B
C
D

2. How many locations does your organization have, and which location(s) would require Mohs coverage?

Section 2: Coverage Needs

3. When would you ideally like coverage to begin?

4. How long do you anticipate needing coverage?

A
B
C
D
E
F

5. Approximately how many Mohs cases do you typically schedule for a full Mohs day?

6. How frequently would you ideally need Mohs coverage?

A
B
C
D
E

If multiple days per month are needed, could those days be scheduled consecutively when possible?

A
B
C

7. Would coverage be needed at one location or multiple locations?

A
B

Section 3: Additional Information

8. Is there anything else about your current staffing transition or Mohs coverage needs that would be helpful for me to know when preparing a proposal?

Section 4: Contact Information

Name

Email Address

Phone Number