EYE SUITES — Client Portal

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Practice Onboarding Questionnaire

Please complete all fields. Your answers are saved automatically to EYE SUITES and your project board.

Practice Information

Legal Name of Practice *

DBA / Trade Name (if different)

Address of OBS Location

Main Phone

Fax

Practice Website

Practice NPI #

Tax / EIN #

DEA registered at OBS address?

Number of Procedure Rooms

Surgeon Information

Surgeon(s) Performing Surgery in the OBS *

Malpractice Carrier

Practice Administrator / Project Lead

Administrator Name

Administrator Email

Administrator Phone

Operations & Billing

Practice Management / EMR System

Where is Billing Performed?

Billing Company Contact Information

Equipment Preferences

Desired Microscope

Desired Phaco Machine

Desired Femto Laser

IOL Preferences / Consignment

Construction & Timeline

Construction Status

OBS Completion Date

Contractor Information

Architect Information

Strategic Insights

What are your primary goals for the OBS suite?

Increase surgical control Improve patient experience Increase profitability Reduce ASC dependence Add premium procedures Other

In your own words: what would make the OBS suite a success for your practice?

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